
Copyright N° 



COPYRIGHT DKPOSm 



A HANDBOOK 

OF 



OBSTETRIC NURSING 

FOR 

NURSES, STUDENTS AND MOTHERS 



COMPRISING THE COURSE OF INSTRUCTION IN OBSTETRIC NURSING 

GIVEN TO THE PUPILS OF THE TRAINING SCHOOL FOR 

3 CONNECTED WITH THE W( 

HOSPITAL OF PHILADELPHIA 



BY 

ANNA M. FULLERTON, M. D. 

FORMERLY OBSTETRICIAN, GYNAECOLOGIST, AND SURGEON TO THE WOMAN'S HOSPITAL 
OF PHILADELPHIA, PHYSICIAN-IN-CHARGE AND SUPERINTENDENT Of ITS 
NURSE SCHOOL: AND CLINICAL PROFESSOR OF GYNAECOLOGY IN THE 
WOMAN'S MEDICAL COLLEGE OF PENNSYLVANIA; LATE LEC- 
TURER ON SURGERY AND* OPERATIVE MIDWIFERY IN THE 
NORTH INDIA SCHOOL OF MEDICINE FOR WOMEN 



SEVENTH REVISED EDITION. ILLUSTRATED 



PHILADELPHIA 

P. BLAKISTON'S SON & CO 

1012 WALNUT STREET 
1911 



^v 



Copyright, 191 i, by Anna M. Fullerton, M. D. 



Printed by 

The Maple Press 

York, Pa. 



©CI.A283442 



THIS LITTLE BOOK IS DEDICATED 
TO 

DR. ANNA E. BROOMALL 

PROFESSOR OF OBSTETRICS IN THE WOMAN'S MEDICAL 
COLLEGE OF PENNSYLVANIA 

IN APPRECIATION OF 

HER ABLE AND FAITHFUL WORK 

AS A TEACHER 



PREFACE TO THE SEVENTH EDITION 



In preparing the seventh edition of this work, the 
previous edition has been carefully revised. A new 
chapter has been added on "The Examintion Dur- 
ing Pregnancy'' and one on "Obstetric Operations." 
Other additions to the text will be found under eclampsia, 
ophthalmia neonatorum, and the care of premature in- 
fants. In the chapter on "Care of the New-born In- 
fant," the modified milk formulae used in the Mater- 
nity of the Woman's Hospital have been substituted 
for certain formulae of the former edition and the di- 
rections for dressing the umbilical cord have been 
changed to conform with the present usage. In the 
treatment of breast abscess, Bier's method of suction 
hyperemia is described. 

Several of the old illustrations have been withdrawn 
and twenty-one new ones have been inserted. The 
typographical work is entirely new. 

Catharine Macfarlane. 

132 South i8th Street, Philadelphia, 
1911. 



Vll 



PREFACE TO THE SIXTH EDITION. 



The methods of procedure advocated in this book 
are those observed in the Maternity of the Woman's 
Hospital of Philadelphia. The results attained by an 
adherence to them have well proved their value. In 
this, as in former editions, I have made an effort to 
bring the teachings of the book up to the requirements 
of modern obstetric practice, and to make the little 
volume a vade me cum of knowledge on the subject; for 
the guidance, not only of the nurse, but of patients and 
physician as well. 

I have to thank Dr. Anna E. Bromall, Professor of 
Obstetrics in the Woman's Medical College of Pennsyl- 
vania, for her kindly aid in the revision of this edition ; 
and my publishers for their efficient help in the manage- 
ment of business details. 

Anna M. Fullerton. 

Fategarh, 
United Provinces, India, 



IX 



CONTENTS 



PAGE 

CHAPTER I. 
The Pelvis i 

CHAPTER II. 
The Pelvic Organs it 

CHAPTER III. 
The Development of the Ovum 19 

CHAPTER IV. 
Signs of Pregnancy 27 

CHAPTER V. 
Management of Pregnancy 38 

CHAPTER VI. 
The Examination During Pregnancy 56 

CHAPTER VII. 
Accidents of Pregnancy 61 

CHAPTER VIII. 

The Anatomy of the Foetal Head and the Mechanism of 

Labor 71 

xi 



Xll CONTENTS. 

PAGB 

CHAPTER IX. 
Preparations for the Labor 88 

CHAPTER X. 
Signs of Approaching Labor — The Process of Labor . . 98 

CHAPTER XL 
Duties of the Nurse During Labor 104 

CHAPTER XII. 
Accidents and Emergencies of Labor 121 

CHAPTER XIII. 
Obstetric Operations 137 

CHAPTER XIV. 
Management of the Lying-in 145 

CHAPTER XV. 
Care of the New-Born Infant . 180 

CHAPTER XVI. 
Characteristics of Infancy in Health and Disease . . . 213 

CHAPTER XVII. 
The Ailments of Early Infancy 224 

Index 269 



LIST OF ILLUSTRATIONS. 



PAGE 

Female Pelvis Showing the Diameters of Pelvic Brim . . 4 
Rachitic Flat Pelvis with Asymmetry and Double Prom- 
ontory (Winckel) 7 

Oblique Pelvis of Naegele 9 

External Genitalia 12 

Cavity of the Uterus and Fallopian Tubes 14 

Breast Showing Enlarged Milk Ducts During Lacta- 
tion (Morris) 16 

Uterus and Ovum at Seventh or Eighth Day 19 

Ovum Cut Open Showing Embryo, Amnion and Chor- 
ion (Edgar) 21 

Placenta and Unruptured Membranes at the Thirty- 
eighth Week (Edgar) 22 

Fcetal Surface of Placenta at Term (Minot) 24 

Human Embryo at End of Second Month (Edgar) . . . 25 
Pregnancy at the Thirty-eighth Week Showing Striae 

(Edgar) 29 

Height of the Fundus and Position of the Cervix in the 

Several Weeks of Gestation (Edgar) 33 

Frozen Section of Uterus from a Primipara at the For- 
tieth Week (Edgar) 35 

Abdominal Belt 41 

Spiral Reverse Bandage of Lower Extremity 46 

Nipple Protector 50 

Measuring the Interspinal Diameter with the Baude- 

locque Pelvimeter 58 

Digital Method of Measuring the Diagonal Conjugate of 

the Pelvic Inlet (Edgar) 60 

xiii 



XIV LIST OF ILLUSTRATIONS. 

PAGE 

20. The Foetal Skull (Diameters) 73 

21. Left Occipitoanterior Postion 75 

22. Right Occipito-anterior Position 75 

23. Right Occipito-posterior Position 76 

24. Left Occipito-posterior Position 76 

25. Presentation of the Face in the Second Facial Position . . 79 

26. Breech Presentation, the Legs Extended 81 

27. Presentation of Right Shoulder 85 

28. Breast Bandage 89 

29. Occlusion Dressing (Garrigues) 90 

30. Suspension of the Asphyxiated Newly Born Child by the 

Feet to Assist Gravity in Freeing the Air-passages 

of Foreign Matter (Edgar) 124 

3 1 . Suspension of the Asphyxiated Newly Born Child by the 

Feet and Cleaning the Posterior Pharynx of Foreign 
Matter (Edgar) 125 

32. Byrd's Method of Artificial Respiration. Position for 

Inspiration (Edgar) 126 

^^. Byrd's Method of Artificial Respiration. Position be- 
tween Inspiration and Expiration (Edgar) 126 

34. Byrd's Method of Artificial Respiration. Position for 

Expiration (Edgar) 127 

35. Prochownik's Method of Resuscitation 128 

36. Prochownik's Method of Resuscitation 128 

37. Position of Patient in Hemorrhage after Labor . . . . 134 

38. Elliott's Modification of Simpson's Forceps (Edgar) . . 140 

39. Tarnier's Axis-traction Forceps (Edgar) 141 

40. Smellie's Scissors Perforator (Edgar) 143 

41. Braun's Cranioclast (Edgar) 143 

42. Nipple Shield 157 

43. Shapes of Nipples 159 

44. Breast-pump 161 

45. Worcester's Y-bandage 163 

46. Obstetrical Breast Support, with Knitted Bosoms . .164 

47. Bier's Hyperemia Apparatus for Mastitis 167 

48. Home-made Bath-tub and Crib 188 



LIST OF ILLUSTRATIONS. XV 

PAGE 

49. Lactometer 194 

50. Sterilizer (Dr. Louis Starr) 208 

51. Graduated Nursing Bottle (Dr. Louis Starr) 210 

52. Rubber Nipple (Starr) 211 

53. Diagram Showing Eruption of Milk Teeth 223 

54. Tarnier's Couveuse 225 

55. Auvard's Couveuse (Interior View) 226 

56. Auvard's Couveuse (Exterior View) 227 

57. Incubator for Premature-born Children (Kny-Scheerer 

Co.) 228 

58. Swaddled Baby 231 

59. Feeder for Premature Infants (Cooke) 235 

60. Single-bulb Syringe (Starr) 245 

61. Arrangement for Irrigation of the Eyes (Dr. Lee) . . . .256 



OBSTETRIC NURSING 



CHAPTER I, 

THE PELVIS. 



The Pelvis is that part of the skeleton found be- 
tween the lower end of the spinal column and the thigh 
bones. It consists of four bones — the sacrum, the 
coccyx, and the right and left innominate or hip bones. 
These bones form a canal through which the child passes 
during labor. 

A knowledge of the anatomy of the pelvis is neces- 
sary to a proper study of midwifery. 

The Sacrum is a triangular or wedge-shaped bone, 
composed of five vertebrae joined firmly together. This 
bone forms a large part of the posterior wall of the 
pelvic canal. It is wedged in between the tw T o innomi- 
nate bones, the base of the wedge being directed upwards, 
and forming by its union with the spinal column a pro- 
jection which is known as the sacro-vertebral angle or 
promontory. 

The effect of this projection is to decrease the 
measurement antero-posteriorly of the pelvic brim, 
making it smaller than any other measurement of the 
brim. Some of the most serious complications of 



2 OBSTETRIC NURSING. 

labor are caused by this narrowing, hence the promon- 
tory is of. great importance obstetrically considered. 
The progress of the child is arrested in its attempt to 
pass through the pelvic canal at this point when the 
contraction is too great. Below the promontory the 
sacrum is curved or hollowed out. This is called the 
concavity of the sacrum and it provides for the proper 
rotation of the child's head during labor. 

The two innominate bones — ossa innominata, or hip 
bones, bound the pelvis in front and on each side. They 
are very irregular in shape and consist of three parts 
which in childhood are indicated by the presence of car- 
tilage which joins the various portions together. The 
upper flaring portions of these bones are called the ilia, 
or haunch bones; the lower portions, the ischia, or seat 
bones; the rami in front, which form the anterior wall of 
the pelvis and the pubic arch, constitute the pubes or 
share bones. The pubic bones are united by a joint in 
front called the symphysis pubis. The union of the in- 
nominate bones with the base and sides of the sacrum 
gives us the two joints called the sacro-iliac articulations, 
the largest and strongest articulations in the whole 
body. 

The Coccyx consists of four rudimentary vertebras 
which are united to the end of the sacrum by a movable 
joint, called the sacro-coccygeal joint. This joint ceases 
to be movable late in life, that is from forty-five to fifty 
years of age. The cartilage in the joint becomes bony 
and thus the joint becomes fixed. This causes a diffi- 



THE PELVIS. 3 

culty in the birth of the child at the outlet of the pelvis, 
as it narrows the antero-posterior measurement f the 
outlet. 

The pelvis is divided by a ridge, called the He o- pec- 
tineal line, into two parts, the true and the false pelvis. 

The false pelvis is that portion which is above the ileo- 
pectineal line, and the true pelvis is below it. The con- 
stricted portion between the two, forming the superior 
circumference of the pelvic canal, is known as the inlet 
or superior strait. The inlet in a normal pelvis is some- 
what heart-shaped. 

The lower circumference of the pelvis is called the 
outlet and is very irregular in shape. 

The cavity of the pelvis which lies between the inlet 
and the outlet constitutes the pelvic canal. When lined 
by the muscles and soft tissues which cover its bony 
walls it is called the parturient canal, or birth canal. 

The cavity is bounded by the sacrum and coccyx, and 
in front by the symphysis pubis. Its sides are formed 
by the lower portions of the innominate bones and the 
soft tissues which fill in the spaces. 

The depth of the pelvic cavity and curvature of the 
sacrum influence the character of the labor. If the 
cavity is shallow and the sacrum only moderately hol- 
lowed out, the labor is likely to be easy and natural ; but 
if the cavity is deep and the curve of the sacrum great, 
the labor may be tedious and difficult. 

In a normal pelvis, the cavity in front measures an 
inch and a half (the depth of the symphysis pubis) ; be- 



4 OBSTETRIC NURSING. 

hind it measures 4 1/2 or 5 inches (the length of the 
sacrum and coccyx) . 

Measurements or Diameters are taken from certain 
parts of the pelvis to determine the capacity of the pelvic 
canal. It is important that every pregnant woman 
should consult a physician in time to have a proper 
estimate made of the size of her pelvis. The measure- 
ments should be taken not later than the seventh month 




Fig. 1. — Female Pelvis showing the Diameters of Pelvic Brim. 

of pregnancy, as it may be desirable for the sake of both 
mother and child that premature labor should be 
induced, or at least some decision made as to the proper 
management of the labor. The most important measure- 
ments to be considered are those of the inlet and outlet. 
The inlet has (1) an antero- posterior diameter called 
also sacro-pubic or true conjugate. This extends from 
the upper border of the pubis in front to the middle of 



THE PELVIS. 5 

the promontory of the sacrum behind. It should 
measure normally about 4 1/2 inches; (2) the trans- 
verse diameter, which gives us the longest measure- 
ment at the inlet, is taken from the middle of the brim 
on one side to the middle of the brim on the other side. 
Its average measurement is from 5 to 5 1/4 inches; (3) 
two oblique diameters. The right oblique diameter 
extends from the right sacro-iliac articulation to the 
left ileo-pectineal eminence ; the left oblique diameter 
extends from the left sacro-iliac articulation to the 
right ileo-pectineal eminence. Each diameter usually 
measures about 5 inches. 

The pelvic canal, or cavity, in the living subject is 
lined with muscles, bound together and covered by 
connective tissue. Blood-vessels and nerves are dis- 
tributed throughout the pelvic cavity, supplying the 
organs and tissues contained in it. 

The pelvic canal forms a curbed tube, its planes at 
different points not being parallel to one another. A plane 
is an imaginary flat surface extending across a tube or 
canal at any point ; and may be represented by placing 
a sheet of paper across the tube at that point. 

The chief planes of the pelvis are: the plane of the 
brim, or inlet, and the plane of the outlet. 

A rod meeting the center of each plane perpendicu- 
larly represents the axis or direction of that plane. 

The axis of the pelvic canal is formed by uniting the 
axes of a series of planes which may be imagined to ex- 
tend across the pelvic canal at various points from the 



6 OBSTETRIC NURSING. 

inlet to the outlet. The curbed line which is thus 
formed represents approximately the direction followed 
by the child's head in its passage through the pelvic 
cavity. 

The plane of the inlet is much more tilted or inclined 
than the plane of the outlet. When this inclination is 
exaggerated, the effect is to make the abdomen very 
pendulous, thus causing, in pregnancy, the head of the 
child to be carried so far beyond the pubes as to make 
it difficult for it to pass through the inlet or to enter it 
in the normal direction. In this way malpresentations 
often atise. 

The female pelvis differs from the male pelvis in the 
following particulars : in the female the bones are lighter, 
the ilia more expanded, the hips thus being made 
broader. The inlet and outlet are larger, the cavity 
larger, the promontory less projecting, the coccyx 
movable, and the arch of the pubes wider. The rela- 
tive width of the transverse diameter is much greater 
in the female pelvis. 

Deformities and Contractions of the Pelvis. — The 
diseases which most commonly cause deformities or con- 
tractions of the pelvis are rickets, or rachitis, and osteo- 
malacia. Diseases of the spine, such as may be caused 
by tuberculous bone abscesses, may cause the vertebrae 
or spine bones to become distorted or dislocated and thus 
affect the shape and capacity of the pelvis. 

Rickets, or rachitis, is the most common cause of pelvic 
abnormalities. It is a disease of childhood and is apt 



THE PELVIS. 7 

not only to distort the pelvis, but to arrest its growth so 
that a rickety pelvis is generally undersized. It is usu- 
ally also flattened, the symphysis pubis being pressed 
back towards the sacrum and the promontory of 
the sacrum bulging forward into the cavity of the pelvis. 
The effect of this is to shorten the antero-posterior 
diameter and to cause a relative lengthening of the 




Fig. 2 . — Rachitic Flat Pelvis with Asymmetry and Double Promontory. 

(Winckel.) 

transverse diameter of the inlet. The cavity of the 
pelvis and the outlet may not be diminished, but, on 
the other hand, expanded in a rickety pelvis. The 
labor in such a pelvis is apt to be affected, as follows: 
If the conjugate diameter is only slightly decreased, 
the presenting part will remain longer than ordinary 
above the brim, and because the head does not fill the 
brim as it should do, the cord may slip down in front 



8 OBSTETRIC NURSING. 

of it or to one side. The os uteri for the same reason 
dilates more slowly. Thus the first stage of labor is pro- 
longed. After the presenting part is sufficiently 
moulded to clear the inlet, the labor progresses normally. 

Sometimes the contraction at the brim is so marked 
that the head may not enter at all and it becomes neces- 
sary to deliver by some operation, as version, delivery 
by forceps, symphysiotomy, craniotomy, etc. 

The osteomalacic pelvis is a deformity caused by the 
softening of the bones in adult life. This leads them to 
yield under pressure and causes great distortion of the 
shape of the pelvis. The pubes assume a peculiar beak- 
like form, and the pelvic canal is very greatly narrowed. 
The disease which causes such deformity occurs most 
frequently in countries where the people are underfed. 
In most cases delivery can only be accomplished by 
means of Caesarean section. The kyphotic pelvis is one 
form of contracted pelvis caused by the pulling back- 
ward of the base of the sacrum. This may result from 
the form of spinal curvature which is commonly known 
as "humpback." The result is that the diameters of 
the inlet are reversed, the conjugate or antero-posterior 
being the longest, and the transverse being the shortest. 
This causes an irregularity in the way in which the head 
of the child enters the inlet , causing the long axis of the 
child's head to enter the conjugate diameter instead of 
an oblique diameter. 

In the funnel-shaped pelvis the outlet is contracted, 
the tuberosities of the ischia being brought nearer to 



THE PELVIS. 



each other and the lower end of the sacrum being pushed 
forward. The pubic arch is diminished, an angle being 
produced. All these conditions tend to delay the ex- 
pulsion of the presenting part at the outlet. 

The oblique pelvis may be the result of lateral curva- 
ture of the spine, or of disease either in the hip- joint or 




Fig. 3. — Oblique Pelvis of Naegele. 

sacro-iliac articulation. Lameness occurring in child- 
hood from any cause may also produce it. The pelvis is 
distorted to one side and thus receives its name. Irreg- 
ularities in the mechanism of labor are caused by this 
deformity and, according to the degree of distortion, 
any of the obstetric operations may be called for, as ver- 
sion, forceps-delivery, craniotomy, etc. 

The spondylolisthetic pelvis results from disease in the 
lumbar vertebrae, at the small of the back. The bones 



IO OBSTETRIC NURSING. 

becoming softened, slip forward into the pelvis and this 
shortens the antero-posterior diameter. This deformity 
is very rare. 

A cleft pelvis is one in which the rami of the pubic 
bones fail to come closely together, the articulation 
being imperfect. This also is very rare and is apt to be 
accompanied by ectropion of the bladder. 

The pelvis ceqitabilites justo minor is smaller in all its 
measurements than a normal pelvis. The labor in this 
case is apt to be tardy because of the contraction. 

The pelvis .cequabilites justo major, or giant pelvis, is 
one which is larger in all its diameters than a normal 
pelvis. This is apt to cause a rapid or precipitate labor. 

Bony tumors and excrescences, and fractures and 
other injuries to the bones of the pelvis may also dim- 
minish the size of the pelvic canal and affect the charac- 
ter of the labor. 

Sufficient has perhaps been said to show the necessity 
for the thorough examination of the pelvis in any case 
of expected labor. 

The muscles and other soft tissues lining the pelvic 
canal form a soft covering for the bones and to some 
extent slightly decrease some of the diameters of the 
pelvis. As they are not otherwise of obstetrical impor- 
tance, the student is referred for their study in detail to 
works on anatomy. 

The same may be said of the blood-vessels and nerves 
supplying these structures. 



CHAPTER II. 

THE PELVIC ORGANS. 

The Internal organs of generation are the uterus, Fal- 
lopian tubes, and ovaries. These are contained within 
the true pelvis. The bladder and the rectum are also 
found in the true pelvis. 

The External Organs are called the " pudenda/' or 
"vulva." 

Immediately above the pubic bone, or anterior border 
of the pelvis, is a cushion of fat, usually covered with 
hair. This is called the "mons veneris." On each side 
of the opening of the vulva are the " labia majora," or 
large lips. Lying beneath these and concealed by them, 
in young women, are two thin folds of flesh, named the 
" labia minora," or "nymphae." They join together 
above, and at their junction is a small projecting body 
called the " clitoris." The small triangular space be- 
tween the clitoris and the nymphae is the " vestibule." 

The opening of the urethra (the "meatus urinarius) , ' ' 
through which the urine escapes from the bladder, is in 
the middle of the lower border of the vestibule. It is 
very important that the nurse should know the exact 
position of the meatus urinarius, as she will frequently 
be called upon to pass the catheter. 

ii 



12 



OBSTETRIC NURSING. 



Below the vestibule is the orifice of the " vagina," the 
canal leading to the uterus, or womb. In virgins a deli- 
cate membrane, usually crescentic in shape, blocks the 

entrance to the vagina. This is the " hymen." 




Fig. 4. — External Genitalia. 
1. The right labium majorum. 2. The fourchette. 3. Right nympha. 
4. Clitoris. 5. Urethral orifice. 6. Vestibule. 7. Orifice of vagina. 8, 
8. Hymen. 9. Orifice of duct of vulvo-vaginal gland. 10. Mons 
veneris. 11. Anal orifice. 

The hymen is usually ruptured at marriage, but a 
woman may be a virgin yet have no hymen; in some 
cases it persists e^en after marriage, and offers an ob- 
struction at childbirth. A woman who has borne chil- 



THE PELVIC ORGANS. 1 3 

dren has a few fleshy projections at the orifice of the 
vagina, the only remains of the hymen, called the "car- 
unculae myrtiformes." Between the vulva and the anus 
is a mass of flesh, the space on the surface measuring one 
and one-half inches in length. During the birth of the 
child this becomes greatly distended, and thins like rub- 
ber. This is the "perineum." It may be torn during 
labor to a greater or less extent; sometimes it is com- 
pletely torn into the bowel. That part of the perineum 
in the virgin which forms the posterior border of the 
vulva is called the "fourchette." It is merely a fold of 
skin, and is almost always torn in a first labor. Behind 
the perineum is the " anus," or orifice of the rectum, the 
lower part of the bowel. 

The Vagina is a canal connecting the external with the 
internal organs of generation. The uterus is at the top 
of the vagina. In front of the uterus is the bladder, and 
behind and to the left the rectum. 

A secretion of mucus keeps the vagina moist. There 
should,. however, be no discharge in a perfectly healthy 
woman. During pregnancy, and as a result of ill 
health or local inflammation, the natural secretion may 
be greatly increased, and the patient is then said to 
have "the whites." In labor the discharge is very 
greatly increased, so as to aid the birth of the child. 

The Uterus is a pear-shaped organ, three inches in 
length, one and one-half inches in breadth, and about 
one inch in thickness. It weighs a little over an ounce 
in its normal condition in a virgin. After child-bearing 



14 



OBSTETRIC NURSING. 



it remains larger and heaver than before. That por- 
tion of the uterus which communicates with the vagina 
is called the "neck, or cervix.' ' The chief portion of 
the organ above this is called the body, and the rounded 
upper surface the fundus. The opening in the cervix 
which communicates with the vagina is called the "os 
uteri." That portion of the cervix in front of the os 
uteri is the anterior lip, while that part which lies behind 
is the posterior lip. 




Fig. 5. — Cavity of the Uterus and Fallopian Tubes. 

A. Superior border or fundus of the womb. B. Cavity of the womb. 
C. Cavity of the neck of the womb. D, D. Canal of the Fallopian tube. 
E, E. The fimbriated extremities. F, F. The ovaries. G. The cavity of 
the vagina. H, H. The ovarian ligments. I, I. The round ligaments. 



The Fallopian Tubes are two canals which pass from 
each side of the upper portion of the uterus. They are 
from three to four and one-half inches long, and will 
admit the passage of a bristle. Each ends in a trumpet- 
shaped opening surrounded by a fringe of small projec- 
tions called ''fimbriae." This is called the fimbriated 
extremity. When the ovum (or egg) escapes from the 



THE PELVIC ORGANS. 1 5 

ovary, it is received by the Fallopian tube and reaches 
the cavity of the uterus in this way. 

The Ovaries are two small flattened bodies about an 
inch long and half an inch thick containing many thou- 
sand germ cells or ovules. They lie about an inch 
from the fundus of the uterus on each side, in the folds 
of the broad ligament. The broad ligaments are folds 
of peritoneum, a thin glistening membrane which covers 
the uterus and all the pelvic organs, and by means of 
which the uterus is suspended in the pelvis. The blad- 
der and rectum being covered with the same tissue, 
there is an intimate connection between the three, so 
that if one is deranged the others are also likely to be 
involved. 

The Breasts are considered as belonging to the ex- 
ternal organs of generation. They are two glands situ- 
ated on the front of the chest, one on each side of the 
breast-bone. They vary in size and shape in different 
women, and during pregnancy they enlarge greatly. 
They secrete milk for the nourishment of the child. 
The nipple at the apex of the gland is a conical-shaped 
projection. The milk ducts all come toward it from the 
different parts of the breast and open on its surface. 
The areola is a pink or brown circle which surrounds the 
nipple. 

There is an intimate connection between the breasts 
and the uterus. Pain in the breast may be the result of 
disease of the uterus. The secretion of milk is called 
''lactation." 



i6 



OBSTETRIC NURSING. 



Menstruation is a bloody discharge from the uterus 
every month. It begins usually about the age of four- 
teen and recurs every month, except during pregnancy 
or while a woman is nursing. There are occasional ex- 
ceptions to this rule. It ceases at the change of life, or 
menopause (usually between forty-five and fifty) . 



Areola 




Milk 
ducts 

Nipple 
or 
Mamilla 



Fig. 6. — Showing enlarged milk ducts during lactation. (Morris.) 

At puberty — that is, when this function first appears 
— the girl becomes a woman, the breasts enlarge, and 
the pelvi's increases in size. The organs of generation 
become ready to perform the functions of reproduction. 
The menstrual flow recurs every twenty-eight days and 



THE PELVIC ORGANS. 1 7 

lasts about four days. The quantity of blood lost at a 
period is from four to eight ounces. Different women 
vary much in this respect. The discharge is blood 
mixed with mucus. Its color is dark red. Any pecu- 
liarity in color, or the appearance of any clots in the 
discharge, will need to be noticed by the nurse and the 
discharge kept for the doctor's inspection. There is 
usually a feeling of discomfort at the menstrual period, 
with headache, pains in the back, breasts, etc. These 
symptoms are more severe in some women than in 
others. The periodic congestion of the uterus, which 
results in the production of the menstrual flow, is prob- 
ably associated with the ripening of the ova or eggs in 
the ovaries called ovulation. It has been found, how- 
ever, that the ova may escape from the ovaries and be 
carried into the uterus through the Fallopian tubes 
independently of menstruation. The ova that do not 
become impregnated are simply carried away by the 
natural discharge. 

Conception most usually takes place immediately or 
very soon after a period. This is not an invariable rule, 
as women have become pregnant before menstruation 
has been established, or even after the menopause. 
They may also become pregnant while nursing. The 
principal disorders of menstruation are : 

Dysmenorrhea, or painful menstruation ; 

Menorrhagia, or excessive flow at the period ; 

Amenorrhea, or suppression of the menstrual flow; 
and 



1 8 OBSTETRIC NURSING. 

Metrorrhagia, the occurrence of hemorrhage between 
the menstrual periods. 

The causes of these disorders are very numerous and 
must be determined by a physician. 



CHAPTER III. 

THE DEVELOPMENT OF THE OVUM. 

Ovulation is the process whereby ovules mature in 
the ovary and are projected from its surface into the 
Fallopian tubes where impregnation usually takes place. 
When an ovule becomes impregnated the mucous lining 




Fig. 7. — Uterus and Ovum at Seventh or Eighth Day, Showing 

Decidua Vera. {Edgar.) 

of the uterus becomes thickened and vascular. The 
fertilized ovule is called an ovum. On reaching the 
uterus it becomes imbedded in the thickened mucous 
membrane which grows around it and forms a covering 

19 



20 OBSTETRIC NURSING. 

known as the decidua reflexa. The remainder of the 
mucous lining of the uterus, with the exception of that 
which lies beneath the attached ovum, is called the 
decidua vera. 

The portion to which the ovum is attached is the 
decidua serotina. The latter with blood-vessels and 
nerves supplied from the walls of the uterus develops 
into the placenta, or after-birth. After the third month 
of pregnancy the decidua vera and the decidua 
reflexa come in contact with each other and unite to 
form one membrane, shreds of which are often seen, 
after a birth, clinging to the outer surface of the chorion, 
or outer layer of the bag of membrane enclosing the 
foetus. 

The chorion in the early stage of its development is 
covered with tufts called villi. Later on many of these 
villi shrink and disappear. Those, however, which are 
next the decidua serotina greatly increase in size and 
number and are penetrated by blood-vessels, running 
from the foetus, thus forming the foetal portion of the 
placenta. 

The amnion is the internal layer of the sac which con- 
tains the foetus. It contains within it the amniotic 
liquid in which the child floats during the time it is 
carried in the uterus. 

The amniotic liquid, or liquor amnii, consists of water 
holding in solution a small quantity of albumen and 
some salts. It is supposed to be secreted by the amnion. 
The amniotic liquid protects the foetus during its life 



THE DEVELOPMENT OF THE OVUM. 21 

within the uterus from shock and jolting, as well as 
from the contractions of the uterus during labor. In 
labor it helps to dilate the uterine os, for being contained 
in the amnion, a pouch is formed which presses down 
into the mouth of the womb, causing it gradually to 
open. 




Fig. 8. — Ovum Cut Open Showing Embryo, Amnion 
and Chorion. {Edgar.) 

The chorion and amnion lie in very close contact with 
each other by the end of gestation. The amnion, a very 
thin, shining membrane, may be peeled off the shaggy 
chorion. It lies also over the foetal surface of the 
placenta and forms a covering for the umbilical cord. 

For the purposes of description the placenta is divided 
into a maternal and fatal portion, but there is no marked 
line of division between them. 



22 OBSTETRIC NURSING. 

The blood-vessels, both arteries and veins, in the part 
of the uterus immediately connected with the placenta 
become enlarged. The veins are developed into large 
channels or sinuses. The arteries running between the 




Fig. 9. — Placenta and Unruptured Membranes at the Thirty- 
eighth Week. (Edgar.) 

uterus and placenta become corkscrew-like as they de- 
velop and are called curling arteries. The arteries 
which come from the foetus through the umbilical cord 
divide and subdivide, so that finally a capillary or hair- 



THE DEVELOPMENT OF THE OVUM. 23 

like vessel runs into a villus. At the extremity of each 
villus the vessel turns back and becomes a vein. The 
little veins from the villi are afterwards gathered to- 
gether into large trunks which unite into the large vein 
of the umbilical cord. 

The circulation of the blood in the foetus is entirely 
separate and distinct from that in the blood-vessels of 
the mother. In the placenta the blood-vessels of the 
foetus, in the chorial villi, lie in close contact with the 
large blood-vessels of the mother. In this way an 
interchange of gases takes place between the maternal 
and the foetal blood. Oxygen and other supplies are 
given to the foetal blood-vessels, and the blood is thus 
purified and replenished. Carbon dioxide and other 
impurities are carried off through the maternal 
circulation. 

The placenta has two surfaces, the fatal and the 
maternal. The internal or foetal surface is smooth, be- 
ing covered by amnion through which the branches of 
the two umbilical arteries and one umbilical vein are 
seen branching out and dividing before they enter the 
substance of the placenta. 

The umbilical cord is usually attached to the placenta 
near the middle of the foetal surface ; but sometimes it 
is attached to the edge, when it is called a battledore pla- 
centa. Very occasionally the cord is attached to the 
membranes, when it is called placenta vellamentosa. 

The placenta is usually about eighteen inches in cir- 
cumference and one or two inches thick. 



24 



OBSTETRIC NURSING. 



In twin births each child has usually its own placenta 
and bag of membranes. Sometimes the placentae are 
attached to the uterine wall at quite separate points. 
Again they are close together and seem fused into one. 
More rarely there is only one placenta for both children 
with a single bag of membranes. When twins are 
found in one amniotic sac they are generally of one sex. 




Fig. io. — Foetal Surface or Placenta at Term. (Minot.) 



The umbilical cord, funis, or navel string is the means 
of communication between the placenta and the foetus. 

The cord varies in length at full term. It may be 
only one foot. Usually it is about two feet. In some 
cases it may be considerably longer. 

Two umbilical arteries and one umbilical vein are found 
in the cord. These are surrounded by a gelatinous mat- 
ter, called Wharton's jelly, which supports the blood- 




THE DEVELOPMENT OF THE OVUM. 25 

vessels. The arteries are twisted around the vein. 
During labor if the cord becomes prolapsed it may be 
seized between the fingers and the foetal pulse — the 
beating of the arteries in the cord — may be felt. Some- 
times knots are found in the cord, which are formed by 
the child passing through a loop in the cord while it 
still floats in the amniotic liquid. These 
are called true knots, to distinguish 
them from false knots, which are simply 
thickened places in the cord caused 
by accumulations of Wharton's jelly. 
Sometimes true knots in the cord are 
drawn so tight that the foetus is killed 
either before or during the delivery by FlG - n.— Human 

. _., Embryo at End of 

the Obstruction OI its Circulation. lhe Second Month. 

term foetus is applied to the product ( Ed z ar -) 
of conception at the end of the third month of 
pregnancy. During the first three months it is 
called an embryo. 

It is desirable that a nurse should understand a few 
facts as to the development of the embryo and foetus dur- 
ing the different months of pregnancy. In the second 
month the head and extremities are visible and the em- 
bryo weighs about 60 grains. In the third month the 
head is out of proportion in size to the rest of the body 
and the embryo weighs about 200 grains. Sex may be 
distinguished in the fourth month. The foetus measures 
about 6 inches and weighs from 4 to 6 ounces. At the 
fifth month the measurement is about 10 inches and the 



26 OBSTETRIC NURSING. 

weight 10 ounces. The nails are beginning to form. 
At the sixth month the foetus is about 12 inches in 
length and weighs one pound. The eyelashes are formed. 
In the male child the testicles are still in the ab- 
domen. By the seventh month the length is about 1 4 
inches and the weight three or four pounds. The eye- 
lids are open and the testicles have descended into the 
scrotum. The skin is wrinkled and very red, and there 
is considerable wooly hair, called lanugo, over the body. 
During the eighth month the foetus measures about 1 9 
inches and weighs from four to five pounds. At the end 
of the ninth month it usually weighs from six and a half 
to 7 pounds, and measures about 20 inches. In some 
cases the child may weigh from eight to ten pounds. It 
is covered at birth with a greasy, whitish material called 
vernix caseosa. 



CHAPTER IV. 

SIGNS OF PREGNANCY. 

The Signs of Pregnancy may be divided into three 
classes: the suspicious, the probable, and the certain. 

Under the head of suspicious signs may be classed the 
many nervous sensations which are apt to accompany 
early pregnancy ; as, general discomfort, sudden changes 
of temperature, headache, toothache, giddiness, faint- 
ness, changes in disposition, perverted appetite, etc. 

Of the probable signs one of the earliest and most con- 
stant is the stoppage of the monthly flow in a person who 
has been regular. This may be, however, caused by 
other conditions than pregnancy. Thus, change in one's 
mode of living, a new climate, or general ill health may 
produce the same result. In the early months of mar- 
riage we may also have an irregularity in menstruation 
where there is no pregnancy. On the other hand, in 
rare instances,, we may have the monthly flow persist- 
ing for some months or throughout the entire pregnancy. 
It is then generally scanty and short in duration. 

A deepening in the color of the vagina and vulva, by 
which they take on a purplish hue, is another sign, and 
is caused by the enlargement of the blood-vessels and a 
stoppage of the circulation, due to pressure from the 

27 



28 OBSTETRIC NURSING. 

enlargement of the uterus. This coloration may be 
caused to some extent by tumors. 

Increase in the size of the breasts occurs in the early 
months of pregnancy with a deposit of coloring matter 
in the areola, or ring which surrounds the nipple. 
Some of this coloring matter seems to extend irregularly 
over the outer margin of the ring, and is called the 
* ' secondary areola ' ' or " areola of Montgomery. ' ' With 
this distention of the breasts there is also a secretion 
found in them — a watery fluid, sometimes yellowish in 
color, known as " colostrum," which appears about the 
third month. 

Temporary distention of the breasts, with the accumu- 
lation of this secretion, may occur in a slighter degree 
as an accompaniment of menstruation, or it may per- 
sist for a long time after a woman has stopped nursing 
her infant. 

Enlargement of the abdomen, which begins about the 
end of the third month of pregnancy, is another impor- 
tant sign. Yet this may also be caused by tumors, or 
by flatulence, or by the deposit of fat in the abdominal 
walls. 

Marks upon the abdomen, due to the rapid stretching 
of the skin, sometimes occur in great numbers, and are 
called " stria" owing to the fact of their resemblance to 
the marks left by whip-lashes. These marks sometimes 
extend down upon the thighs. This, too, may be 
caused by tumors. The " brown line" of pregnancy is 
the deposit of pigment in the median line of the abdomen. 






SIGNS OF PREGNANCY, 



2 9 



This may exist when there is no pregnancy, as also may 
the peculiar browning of the skin found in irregular 




patches over the face, particularly on the forehead, and 
called the "mask of pregnancy." 



3° 



OBSTETRIC NURSING. 



" Morning Sickness," another sign, begins early in 
the second month or at the time of the first missed 

i e 
ts 




pr 

Q 

lower portion of the posterior wall of the uterus^ancra[e 
increase of the antero-posterior diameter of that organ, 
as discovered by what is known as bi-manual palpa- 



SIGNS OF PREGNANCY. 3 1 

tion — one finger of the examiner resting over the pos- 
terior wall of the uterus through the rectum, while the 
other hand makes pressure over the lower part of the 
abdomen. 

Another sign is that afforded by the thermometer, 
when its bulb is carried within the cervical canal. If 
pregnancy exist, the temperature is said to be from a 
half to one degree higher than in the vagina. 

The pulse of a pregnant woman is said also to show 
less variation from change .in position than that which 
occurs in the non-pregnant state. Thus, the change 
from lying to sitting or standing does not cause a quick- 
ening, such as is usually observed in the non-pregnant 
state. 

The uterine souffle is a blowing sound which is sup- 
posed to occur in consequence of the enlargement of the 
blood-vessels of the uterus, and which, therefore, cor- 
responds in its rhythm with the radial pulse of the 
patient. This must not be confounded with the funic 
souffle, a blowing sound which sometimes occurs in the 
vessels of the cord, and which is synchronous with the 
foetal pulse, therefore about twice as rapid as the 
mother's pulse. 

When the uterus is large enough to be felt through 
the abdominal walls, palpation over it is apt to cause a 
contraction, which is indicated by a temporary harden- 
ing. This is another indication of pregnancy. 

The positive signs of pregnancy as agreed upon by 
most obstetricians are but two : the direct appreciation 



32 OBSTETRIC NURSING. 

of the parts of the child by touch, and the " foetal pulse, ' ' 
or heart sounds of the child. The " foetal pulse ' ' is, as a 
rule, twice as fast as the pulse of the mother. It is 
hardly strong enough to be heard, even by experienced 
ears, much before the fifth month — or end of the twen- 
tieth week; rarely heard well before the twenty-fourth 
week. 

Methods of Determining Date of Confinement. — 
The ordinary method of reckoning the probable date of 
confinement is as follows : Learn on what day the last 
monthly flow began, then count three months back- 
ward (or nine months forward) and add seven days. 
For example, say that a woman was unwell last on March 
15: counting three months back gives December 15; 
add seven days, and we have December 22 as the prob- 
able date of her confinement. All methods of reckon- 
ing are only approximate. It is best to consider the 
date calculated as the middle of a period of two weeks, 
within which labor may occur at any time. When, for 
any reason, it is impossible to make the calculation by 
this method, it may be computed by adding four and a 
half months to the date of quickening in the case of a 
woman pregnant for the first time, and five months in 
the case of one who has previously borne children. 

The third method, that of adding forty weeks, or ten 
lunar months, to the date of conception, is too uncer- 
tain to be of much practical use. Examination of the 
patient by an intelligent physician who knows and 
appreciates the distinctive signs of the several months 



SIGNS OF PREGNANCY, 



33 



offers a fourth method of computing the date of 
pregnancy. 

Some of the more important of these distinctive signs 
may be mentioned, as determined both by external and 




Fig. 13. — Height of the Fundus and Position of the Cervix 
in the Several Weeks of Gestation. (Edgar.) 

internal examination. During the first month of preg- 
nancy the uterus, because of its weight, sinks lower 
than before, so that the abdomen is flattened, the navel 
being depressed. It is not until the end of the fourth 
3 



34 OBSTETRIC NURSING. 

lunar month that the uterus rises above the brim of the 
pelvis. About the middle of the fifth month the fundus 
of the uterus may be felt about midway between the 
umbilicus and the pubes. By the end of the sixth 
month it reaches to the height of the umbilicus. By 
the end of the seventh month it is three fingers' breadth 
above the umbilicus. By the ninth month it has reached 
almost to the lower end of the breast-bone, and dur- 
ing the tenth lunar month it sinks to a point about mid- 
way between the umbilicus and lower end of the breast 
bone. This is caused by the head of the child pressing 
down into the pelvic canal, thus the abdomen is made to 
look smaller than it did just before the descent. By 
making an internal examination, — that is, carrying a 
finger up into the vagina, the head of the child may be 
felt through the tissues of the neck of the uterus and 
will be found to lie quite low. In the earlier months 
before the presenting part has engaged, it will be diffi- 
cult to reach by the examining finger and the neck of 
the uterus will not be found to be obliterated. 

During the latter part of the last month of pregnancy, 
there is a gradual stretching of the lower segment of the 
uterus, the cavity of the body of the uterus and the cer- 
vical canal are made to communicate by the widening of 
the internal os uteri, until finally the two are made to 
form but one cavity and the external uterine os is felt as 
a small opening lying directly in contact with the pre- 
senting part. 

The settling of the child, causing the descent of the 



SIGNS OF PREGNANCY. 35 

uterus, produces a relaxation of the abdominal walls 
and a pouting of the umbilicus during the last month of 
pregnancy. 

During the last weeks of pregnancy the position of the 
foetus in the uterus may be determined by palpation 
over the abdomen. The patient should lie on her back 




Fig. 14. — Frozen Section of Uterus From a Primipara at the 
Fortieth Week. (Edgar.) 

with her lower limbs drawn up and the abdomen un- 
covered. The body of the child may then be felt by 
passing the hands over the abdomen, and the position in 
which it lies thus determined. 

In multiple pregnancy more than one child exists. 
Twin pregnancy occurs once in about 90 cases. Trip- 
lets are very rare, — occurring once in about 8,000 
labors. . Larger numbers at one birth are still less fre- 



36 OBSTETRIC NURSING. 

quent. In multiple pregnancies the shape of the abdo- 
men differs from that seen in single pregnancies. The 
abdomen is broader across and more irregular in shape. 
Sometimes in twins pregnancy, if the abdominal walls 
are thin, a furrow or depression may be seen between the 
two foetuses. On palpation, also, two separate foetal 
heads and foetal trunks may be made out. On auscul- 
tation two distinct foetal hearts may be made out. 

Extra-uterine or ectopic pregnancy occurs outside the 
uterus. When it takes place in the peritoneal cavity it 
is called abdominal pregnancy ; when in the ovary, it is 
known as ovarian pregnancy; when in the Fallopian 
tubes, it is called tubal pregnancy. Tubal pregnancy 
is the most common of these forms. The gestation sac 
usually bursts about the third or fourth month, and the 
patient may lose her life unless she receives the prompt 
attention of a good surgeon. All extra-uterine preg- 
nancies are abnormal conditions and when suspected 
should receive prompt medical attention. The signs 
of early pregnancy exist but the uterus fails to enlarge 
regularly, and severe cramp-like pains with blood 
discharges are apt to recur at intervals. 

Numerous tables for a rapid computation of the date 
of confinement have been made. The accompanying 
table is one much used. By taking the upper figure in 
each pair of horizontal lines as representing the date of 
the first day of the last menstrual period, the figure im- 
mediately beneath it will represent the probable date of 
confinement. 



SIGNS OF PREGNANCY. 



37 



CO 


t^ 


o 

■re 


so 


OS 
cm 


IQ 


00 
CM 


^ 


CM 


CO 


CO 
CM 


CM 


o 
CM 


r-H 


CM 


t-H 
CO 


CO 
CM 


o 

CO 


CM 
CM 


OS 
CM 


CM 


00 
CM 


O 
CM 


CM 


OS 


CO 
CM 


00 


CM 


r^ 


CM 



S S3 



T-H OO 

o t- 



00 lO 
CM 



CM 



CO CO 
CM 



S 



-*J< T-H 

CM 

CO O 

CM CO 

CM OS 

CM CM 

T-H CO 

CM CM 

O t>- 

CM CM 



OO lO 
t-h CM 



t-h 00 

T-H T-H 

O i>- 



CO T-H 

CM CO 



S3 °° 

CM CM 
CM t~- 
CM CM 

T-H so 

CM CM 

£ *° 

CM CM 

OS -*f< 
t-h CM 

%% 

*>• CM 

t-h CM 



t-i CM 

»o O 

t-h CM 

■* OS 

»— 1 T-H 

CO 00 

t-H T-H 

CM I>- 

t-H t-H 

t-H CO 

-t-H t-H 

o io 



OS CO 
CM 



^*H OS 
CM CM 



T-l CO 

CM CM 



23 



TJH OS 

T-H T-H 

CO oo 

t-H T-H 

CM !>■ 

i-H t-H 

r-H CO 

T-H t-H 

o »o 



co I s - 

CM CM 



CM CO 
CM CM 



O ^ 
CM CM 



os co 

t-h CM 



O0 CM 

t-h CM 



CO o 
t=! CM 

iO OS 



^ 00 

co «>- 

1-H T-H 

CM 55 

T-H T-H 

T-H O 



O "* 

OS CO 

00 CM 

*" 3 

CO o 

»o OS 

T* 00 

CO t* 

CM CD 

i-H iC 



CM CO 



CO O 
CM CO 



CM OS 
CM CM 



t-H O0 

CM CM 



O t^ 
CM CM 



CM OS 

T-H T-H 

t-H 00 

o t- 



CO 





CM 


CO 
CM 


O 

T-H 


LO 

CM 


00 


<* 

CM 


*> 


CO 
CM 


CO 


CM 
CM 



t-H 1^- 

O CO 



OS *C 
CM 



t^ CO 
CM 



CO CM 
CM 



CO o 
CM CO 



CM OS 
CM CM 



CM CM 



00 IO 
t-H CM 



iO CM 

t-h CM 



T-H 00 
T-H T-H 

O t>- 






CM OS 

T-H CO 

T-H T-H 

o c^ 



00 to 

t-h CM 



H 00 

T-H T-H 

O t^ 



00 -<* 

CM 



r>. co 



CO O 
CM CO 



CM OS 
CM CM 



T-H 00 

CM CM 



O t^ 
CM CM 



OS CO 
t-h CM 



CO to 
t-h CM 



CO CO 

T-i CM 



iO CM 
t-h CM 



00 S 
t-h CM 



CM OS 



T-l 00 



o 1^ 

OS CO 

T-H 

00 »o 

t-H 

CO CO 

T-H 

iO CM 

T-H 

T* T-H 

T-H 

CO o 

T-H 

CM OS 

T-i CO 



CO 

O CO 
CO 

OS id 
CM 

00 -* 

CM 

t- CO 
CM 

CO CM 
CM 

»0 T-H 

CM 

T* © 

CM CO 

CO OS 
CM CM 

CM 00 
CM CM 



O CO 
CM CM 



t* o 

t-h CM 

CO OS 

T-H T-H 



1— I l>- 

O CO 



OS CO '■ OS co 



00 to 

r- -* 

CO CO 

IO CM 



00 tO 
|>. T^ 

T-H 

CO CO 

*0 CM «0 

"^ t— I rji 



CO O ' CO o 



CM OS 

t-h OO 



CM OS 

t-H CO 



OS "* 

00 co 

T-H 

I>- CM 

T-H 

CO tH 

tO o 
•<* OS 

co 00 

CM t^ 

T-H CO 



OS CO 

T-H 

CO to 

T-H 

t- T*l 

T-H 

CO CO 
iO CM 

T* T-H 

CO O 
CM OS 

t-h 00 



OS CO 
00 iO 

T-H 

t-H 
CO CO 

iO CM 

T-H 

-<* T-H 

T-H 

CO O 

T-H 

CM OS 

T-l CO 



OS CO 

T-H 

00 iO 

t>- ^ 

CO CO 

iO CM 

-^ T-l 

CO o 

CM OS 

t-i CO 



OS CO 

T-H 

00 »o 

T-H 

r>- •* 

T-H 

CO CO 

T-H 

tO CM 

T— I 

tH t-i 

CO O 

CM OS 

t-H 00 






t£ 

CO Ca 



< ^ 






TH Q 



►=>^ 






CD S 
03 •*•> 



o ^ 



> CIO 

o- § 



OS to 

CO "<* 

t^ co 

CO CM 

tO T-H 

-T*l O 

co os 

CM 00 

T-l t>. 



«t\ 



o 



CHAPTER V. 

MANAGEMENT OF PREGNANCY. 

The management of pregnancy consists, for the most 
part, in greater attention to the laws of health. The 
increased activity of all the organs of the body, together 
with the disturbances caused by pressure, necessitates 
this. 

Constipation is an almost invariable accompaniment 
of pregnancy. In the early months it is a sympathetic 
condition; later, the effect of direct pressure upon the 
bowels. It is also, undoubtedly, in part due to the 
want of exercise. 

The treatment of constipation is the same as in other 
conditions, except that only mild laxatives are used. 
Regularity in attention to the bowels, a glass of hot 
water at night and again in the morning, liquids (either 
milk or water), not taken with the meals, but in the in- 
tervals, a teaspoonful of common salt in the water occa- 
sionally, the use of uncooked fruit and coarse bread, the 
avoidance of starches and fine flour — all these are help- 
ful in overcoming this condition. There is an objection 
to the use of sugared fruits, as confection of fruit, 
senna leaves, etc., because of their liability to disturb 
the stomach. Prunes are, perhaps, the least objection- 
able; licorice powder, because of the senna which it 

38 



MANAGEMENT OF PREGNANCY. 39 

contains, is apt to cause griping pains. Rhubarb is, 
perhaps, the best of the mild laxatives. A small piece 
of rhubarb root, the size of a pea, may be taken at 
night, followed by a glass of water. If there is an objec- 
tion to its taste, it may be taken in pill form. Fluid 
extract of cascara sagrada with an equal amount of 
glycerine is useful. 

Cream of tartar, a half teaspoonful being taken at 
night in a cup of cold water, is often efficient. In some 
cases it may be necessary to repeat the dose in the 
morning. 

Massage of the abdomen, so efficient in the manage- 
ment of constipation, should never be resorted to in the 
pregnant state, as it is apt to excite uterine contractions 
and may lead to miscarriage. There is an objection to 
the too frequent use of enemata on the same ground; 
also, the habit is thus acquired of depending upon this 
stimulus, and overdistention of the bowel is the result. 
It may be necessary, however, occasionally to alternate 
an enema with a laxative, especially when the patient 
suffers from piles. 

Diarrhea is rather a rare disturbance of pregnancy, 
but it sometimes occurs as a direct result of constipa- 
tion — small, hardened masses forming in the bowel, 
known as " scybala," which produce an irritation of the 
mucous lining. The use of rhubarb night and morning, 
in the manner described above, until all the masses are 
removed from the bowels, will serve to check the 
diarrhea. Should the condition be due to other causes, 



40 OBSTETRIC NURSING. 

as indigestion, etc., appropriate remedies will have to be 
prescribed by a physician. 

Changes in the Urinary Organs are mainly due to 
direct pressure. In the first three months of pregnancy 
there is direct pressure on the bladder, hence great irri- 
tation, due to interference with the distention of the 
bladder, producing a constant desire to pass water. For 
this the recumbent position is the only help. The 
uterus rises in the abdomen at the end of the third 
month, and the bladder being thus relieved from pres- 
sure, this symptom passes away. 

The tendency from the fourth to the ninth month is to 
the accumulation of urine, because there is less than the 
proper irritability of the bladder, the organ being flat- 
tened between the uterus and the abdominal walls, and 
its walls thereby suffering a partial paralysis. 

In the last month there is incontinence of urine, be- 
cause the pressure is so great that there is no room for 
the accumulation of urine. 

During labor there is pressure upon the neck of the 
bladder and urethra, leading to retention. This may 
exist for the last two weeks of pregnancy. Necessity 
for the use of the catheter is confined, as a rule, to this 
period. The distention of the bladder may impede 
labor. With the drawing up of the uterus the bladder 
is drawn up and the urethra elongated, hence a long 
catheter will be necessary. Some use the English rub- 
ber catheter, Nos. 8 and 9. The glass catheter care- 
fully used is best. 



MANAGEMENT OF PREGNANCY. 



41 




Fig. 15. — Abdominal Belt. 



Sometimes irritability of the bladder is due to exces- 
sive acidity of the urine. A physician will generally 
prescribe some alkali to overcome this condition, as a 
drop of liquor potassa in a tablespoonful of milk once 
in three or four hours, or the use 
of mucilaginous drinks, as flax- 
seed tea, barley water, milk, etc. , 
may relieve the distress. 

When the abdominal walls 
are much stretched and the 
uterus falls upon the bladder, 
this may be remedied by the 
use of the binder or an abdominal supporter. 

Incontinence of Urine leads to the excoriation and 
reddening of the parts about the vulva. Frequent 
washing with warm water and borax or pure Castile 
soap relieves the irritation. Diachylon or zinc oint- 
ment is best when an ointment is needed. 

Incontinence is sometimes the result of overdisten- 
tion of the bladder. Here the use of the catheter is 
indicated. 

A nurse, unless thoroughly experienced, should never 
attempt to pass the catheter in the case of a pregnant 
woman, as serious injury may be done to the soft parts 
in a bungling attempt. In all cases she should have the 
sanction of the physician before doing so. 

The Kidneys are especially subjected to pressure 
from the seventh to the ninth month of pregnancy. A 
passive congestion is thus produced, which may lead to 



42 OBSTETRIC NURSING. 

the occurrence of albuminuria, or albumin in the urine. 
This is an evidence of a drain upon the blood which 
the physician heeds to watch very carefully. It is cus- 
tomary, therefore, for physicians to examine the urine 
of patients whom they expect to attend at least once a 
week, from the seventh month on to the termination of 
pregnancy. Scanty urine, headache and impairment 
or vision may be symptoms of grave kidney disease 
and should be reported to the physician promptly. 

Examination of Urine. — The urine obtained on first 
emptying the bladder in the morning before break- 
fast, if possible, is the most satisfactory for examin- 
ation. When a small quantity of albumin is present in 
urine, it is often increased after a meal. The same is 
true of sugar. A specimen obtained by the use of the 
catheter is the best for the purpose, if the patient be 
troubled by a discharge from the vagina. 

It is important also to note the amount of urine passed 
daily during pregnancy. The nurse in attendance 
upon a patient who is awaiting her delivery should 
make a daily record of the amount passed, to keep 
the physician informed as to the work done by the 
kidneys. 

The average quantity of urine excreted in twenty- four 
hours in health during the non-pregnant state is about 
three pints, or fifty ounces. A clean vessel, set aside 
for the patient's exclusive use, should be used by her 
each time that the bladder needs to be emptied during 
the entire twenty-four hours. The nurse then measures 



MANAGEMENT OF PREGNANCY. 43 

the amount, using for the purpose a graduate set aside 
for the work, or some other vessel of known capacity. 

The color of the urine will need to be noted by the 
nurse, in her record. The natural color is clear, pale 
yellow, or amber. Substances taken by the patient, as 
food or medicine, or conditions of disease may cause the 
color to vary, or render the urine turbid. 

There is a natural increase in the amount of urine 
passed by a pregnant woman, but the increase is mainly 
in the water. Therefore the urine will be lighter col- 
ored than usual. 

The reaction of the urine should be acid. Small strips 
of blue and pink litmus-paper (that is, paper colored by 
a delicate coloring matter known as litmus) should be 
kept on hand for the purpose of testing the urine while 
fresh. When a strip of the blue litmus-paper dipped 
into the urine turns pink, we know the urine is acid; 
w T hen the pink paper is made to turn blue, the urine is 
alkaline; when no impression is made on either, it is 
neutral. 

Usually the estimate of the amount passed in twenty- 
four hours, and a record of the color and reaction 
cover the requirements of a nurse's observations of the 
urine. Sometimes, however, a physician requires the 
nurse to test daily for the presence of albumin. This 
test is effected as follows: Fill a test-tube one- 
quarter or one-third full of clear urine (after filter- 
ing the urine, if cloudy, through filter paper). If the 
urine is not distinctly acid in reaction, add a few drops 



44 OBSTETRIC NURSING. 

of acetic acid. Boil the fluid over an alcohol lamp, 
directing the flame to the upper part of the urine. If a 
cloudiness appears, it is thus at once contrasted with the 
clear urine of the lower layer, as the tube is held up toward 
the light. This cloudiness may be due to albumin or 
earthy phosphates. A few drops of nitric acid, if added, 
will make the phosphates disappear but not the 
albumin. 

Leucorrhea, a discharge from the vagina, commonly 
known as "the whites," is often considerably increased 
during pregnancy, and is due to the greater activity in 
the secretion of all the mucous membranes. If a vaginal 
discharge be of white, yellow, or green color, it indicates 
inflammation of the vagina itself. The discharge, on 
reaching the vulva and coming in contact with the air, 
decomposes and becomes irritating. Cleanliness is im- 
portant in overcoming the effects of this. The itching 
induced by it is sometimes very obstinate, and generally 
worse at night. A solution of borax and water for 
bathing the parts, or carbolic acid, 15 to 20 itl to a pint 
of water, will often give relief. Should vaginal injec- 
tions be ordered by the physician, they should be given 
with great caution. A fountain syringe should be used, 
which produces a continuous stream, and the rubber 
bag or reservoir containing the water should not be held 
higher than two feet above the level of the bed or couch 
on which the patient lies. The interrupted stream 
should never be employed. In some conditions of ex- 
cessive discharge the physician may prescribe tannic 



MANAGEMENT OF PREGNANCY. 45 

acid suppositories to be used nightly in the vagina. 
After a thorough drying of the parts surrounding the 
vulva, they may be dusted with a powder consisting of 
one part powdered camphor to four parts starch. This 
often gives great relief. Calomel powder may be used 
in the same way. 4 

Hemorrhoids, or Piles, are often very troublesome 
during the latter part of pregnancy. Lying down im- 
mediately after a movement of the bowels, and remain- 
ing in the recumbent position for ten to fifteen minutes, 
will tend to relieve them, also care in obtaining a daily 
evacution of the bowels, and the use of means to secure 
as soft a movement as possible. Should the piles come 
down, they should be fomented by cloths wrung out in 
hot water, to which a little Pond's Extract or fluid ex- 
tract of hamamelis may be added, — one tablespoonful, 
or two, to one pint of water, — and when shrunken, 
anointed with cold cream or cosmolin, or any ointment 
prescribed by the physician, and returned into the 
bowel. 

Sometimes the case is so aggravated as to necessitate 
keeping the patient in bed for a time. A physician- 
should, of course, be consulted about the treatment. 

Swelling and Pain of the external organs of gene- 
ration and of the lower limbs, resulting from pressure 
and the overdistention of the blood-vessels, is best re- 
lieved by the recumbent posture. 

Should the veins of the legs be much enlarged or the 
feet swollen, the patient should have compression made 



4 6 



OBSTETRIC NURSING. 



over them by the application of a bandage (the spiral 
reverse of the lower limb) , or she should wear an elastic 
stocking, such as may be obtained of any good instru- 




Fig. 16. — Spiral Reverse Bandage of Lower Extremity. 

ment maker. For the bandage the best material is 
flannel cut bias, the width being about three inches. 
The bias bandage makes more even compression. 
Great harm may result, from the neglect of enlarged 



MANAGEMENT OF PREGNANCY. 47 

veins, as they sometimes become so distended as to 
burst. Prof. T. S. K. Morton has devised a method of 
putting on a spiral bandage of the lower extremity, 
which retains its place better than that just described, 
which is apt to loosen when the patient moves about. 
Dr. Morton begins the application of his bandage as in 
the ordinary spiral reverse bandage of the lower limb, 
but carries oblique turns up and down the limb until its 
surface is entirely covered, in place of making reverses. 
When this bandage is further secured in place by carry- 
ing a running line of stitches up both the inner and outer 
side of the limb, it keeps its place perfectly and is quite 
as serviceable as an elastic stocking. 

Pain caused by the stretching of the walls of the 
abdomen my be relieved by thorough inunction of the 
skin. Cotton-seed, olive, or cocoanut oil may be used 
for the purpose. 

Severe pains in the back, neuralgic in character and so 
severe sometimes as to prevent the patient from sleeping, 
may yield to change of position, relieving pressure. 
Rubbing with soap liniment, volatile liniment, whisky, 
or any liniment not too active, is helpful. Warm hip- 
baths may sometimes be prescribed by a physician. 

The Salivary Glands are in some cases very active dur- 
ing pregnancy, inducing so excessive a secretion of 
saliva as to cause the patient great annoyance. This 
trouble is generally very intractable, and may refuse to 
yield to all treatment, ceasing only with parturition. 
Astringent washes, as of tannic acid, alum, myrrh, etc., 



48 OBSTETRIC NURSING. 

may be tried, as also the use of pieces of ice. Physicians 
sometimes use atropia in small doses. Its use requires 
careful watching. 

Bad Teeth, which occur often during pregnancy, 
are said to be due to acidity of the saliva. A little 
baking soda or prepared chalk placed in the mouth at 
night will counteract the effect of this acidity when it 
exists, or milk of magnesia may be used as a mouth 
wash, a teaspoonful being distributed systematically 
around the teeth after each meal and at bedtime. 
The question is often asked whether there is any danger 
in having the teeth filled or attended to during preg- 
nancy. There is always some danger, because a certain 
amount of nerve-irritation is the result. If the patient 
be suffering, however, it is better to have them filled by 
a temporary rubber filling, which causes little pain or irri- 
tation, than to lose rest in consequence of toothache. 
Extraction of the teeth should only be allowed when 
absolutely necessary. If the pain be simply a neuralgic 
pain, it is better to wait. 

Vomiting is, as has been mentioned in the preceding 
chapter, a most common accompaniment of pregnancy. 
It more frequently exists, perhaps, with the first preg- 
nancy than any other. The act is accomplished, as a 
rule, without much effort. Diet seems to have little 
effect upon it. Various articles have been recom- 
mended for it, as rice water, beef -tea, barley-water, the 
various gruels, the yolk of a hard-boiled egg, scraped 
beef, in the form of sandwiches, ice-cream, cracked ice, 



MANAGEMENT OF PREGNANCY. . 49 

etc. In some cases one or another of these seems to 
relieve the irritation. A cup of coffee, weak tea, or 
milk, taken warm early in the morning before the 
patient raises her head from the pillow, will often act as 
a preventive. In extreme cases of vomiting rectal 
feeding must be resorted to. In obstinate vomiting 
it is important that the physician should examine for 
the position of the uterus or the existence of ulcera- 
tions or erosions. 

It must not be forgotten that the constant loss of 
food may be so great a drain upon the patient's strength 
as to endanger her life. As this symptom is so largely 
sympathetic, the proper use of bromides or other nerve- 
sedatives prescribed by a physician may be of great use 
in checking it. In all cases of excessive vomiting a 
careful record of the pulse rate should be kept, for a 
pulse of 100 or above indicates a serious condition. 

Care of the Breasts in a pregnant woman necessi- 
tates careful attention to the prevention of compression. 
Full development should be permitted by the looseness 
of the - clothing. The importance of the proper dress- 
ing of growing girls cannot be overestimated in this 
connection. Did mothers realize the evil — of which 
the atrophy of the breasts is but one — resulting from 
tight lacing, there would be fewer unhealthy women 
and fewer mothers unable to nurse their offspring. The 
nipples should be prevented from rubbing, and the skin 
over the nipples should be strengthened by using the 
nipple-bath — filling a small, wide-mouthed bottle one- 
4 



50 OBSTETRIC NURSING. 

third full of cold water and inverting it over the nipples 
daily, from five to ten minutes at a time. Sometimes a 
little cologne-water or alcohol is added to the nipple- 
bath, or, better still, borax in the proportion of one 
tablespoonful to the pint of water. Keeping off crusts 
and concretions of various kinds from the surface of the 

nipples by the daily use of olive oil 

€~2§p and alcohol, equal parts, is very satis- 

^^^^ MJ ~~^^^^ factory. This keeps the skin pliable. 

^mmmum^^^^ The use of the nipple protector, which 

Fig^ 17.— Nipple w {\i b e referred to more fully in the 

Pp o trot* op 

chapter on the management of the 
lying-in, is of great importance where there is a 
tendency to flattening of the nipple, to remove the 
pressure of the clothing. Drawing out the nipple 
gently between the thumb and finger is also helpful in 
overcoming this tendency. 

The Clothing of a pregnant woman should be worn 
loose from the very beginning, both because the breasts 
begin to enlarge early and because any amount of pres- 
sure upon the intestines tends to produce uterine dis- 
placements, which are especially dangerous during 
pregnancy, as they predispose to abortion. The cloth- 
ing must be warm but light in weight, it should be 
supported from the shoulders. Next to the skin the 
patient should wear a union suit of wool or Deimel 
mesh. Over this, up to the fifth month, a comfortable 
straight-front corset may be worn, providing it does 
not constrict the waist; from the fifth month on the 



MANAGEMENT OF PREGNANCY. 5 1 

enlarging uterus should be supported from below and 
the ordinary forms of corsets must be abandoned; a 
maternity corset, such as Berthe May's or Van Orden's, 
should now be worn or an elastic abdominal belt 
and separate breast supporter. Over the corset a 
chemise may be worn and a light weight silk skirt 
with adjustable band. The gown is preferably a loose 
one-piece affair made on a princess foundation or a 
two-piece suit consisting of an adjustable " maternity" 
skirt and a jacket or blouse to be worn outside of 
the skirt. For street wear, a long, loose wrap will be 
required which must not be heavy. 

It is well for the stockings to be of wool or silk and 
side, suspender garters should be worn. 

The shoes or slippers should be comfortable and 
with broad soles and low heels. 

Many physicians insist that flannel should be worn — 
at least during pregnancy — both summer and winter. 
A lighter flannel can be substituted in summer for that 
which would be worn in winter. The use of flannel is 
to prevent chilling of the surface, and this is especially 
important where — as in pregnancy — the kidneys are 
overworked. It is important also for the condition of 
the heart and lungs. Coughs often cause premature 
labors. 

Bathing is very necessary for a patient during her 
pregnancy, as at other times. As regards the character 
of the bath, she can do as she has been accustomed to, 
using warm or cold water. A change from warm to 



$2 OBSTETRIC NURSING. 

cold water, or vice versa, is, however, not allowable. A 
sponge-bath, followed by brisk rubbing, is the most de- 
sirable. The skin is thus kept in good condition. 
Shower-baths should be avoided, also the shock of sea- 
bathing. 

Sea Voyages are injurious, because of the danger of 
receiving falls or blows in consequence of the motion of 
the vessel, and also because of the liability to sea-sick- 
ness induced by them. When it is absolutely neces- 
sary to take a sea voyage, there is probably least danger 
in the last three months of pregnancy, because the pla- 
centa, or afterbirth, is then well developed and its at- 
tachment to the uterus close. 

The Regulation of the Diet during pregnancy is of great 
importance. A patient should eat heartily for break- 
fast and dinner, but the evening meal should be light, 
especially from the seventh month on to the close of 
pregnancy. This meal should consist of stale bread, 
with butter and cooked fruit, as stewed apples, and a 
glass of milk or weak tea. Digestion is less active in 
the latter part of the day, and often a hearty meal may 
prov^e the direct exciting cause of convulsions. The 
food should be plain, wholesome, nourishing, well- 
cooked, and chosen in each case with special reference 
to the avoidance of digestive disturbances and constipa- 
tion. Meat in moderate quantity, broths, milk, eggs, 
and fresh fruit should constitute an important part of 
the dietary. Pastry and confections should be avoided. 

There is a mistaken theory prevalent in this day that 



MANAGEMENT OF PREGNANCY. 53 

a mother, by abstaining from certain kinds of food, as 
meat, eggs, milk, etc., and confining herself chiefly to a 
fruit diet, may thus, by preventing the hardening of the 
bones of the child, do away largely with the pains of 
labor. The truth of the matter is this: that during 
pregnancy all the functions of the mother's body are 
especially active in promoting the development of the 
child, hence an insufficient supply of essentially nourish- 
ing food will first affect the mother's system and render 
her unfit for the demands upon her strength at the time 
of parturition. 

Should a restriction to the fruit diet effect w T hat it is 
claimed to do as regards the infant, it would result in the 
production of sickly, rachitic children, poorly developed 
mentally and physically. 

Moderate Exercise is essential during pregnancy. 
Walking on a level, not riding, is the best form of exer- 
cise. A daily walk should be taken, not, however, after 
nightfall. The patient should avoid lifting — in fact, 
all straining movements — and most particularly should 
she avoid the use of the sewing-machine. Exercise, 
judiciously taken by the pregnant woman, serves to pre- 
vent undue development in the size of the child, and in 
this way serves to make her labor easier. 

Maternal Emotions. — There is sufficient proof that 
the mother's emotions influence the child to render it 
important that her surroundings during pregnancy 
should be as pleasant as possible, and that she should 
avoid fright or any violent emotion. At the same time 



54 OBSTETRIC NURSING. 

there is no ground for the popular belief that when a 
pregnant woman is thus frightened her child will be 
" marked.' ' 

Complications of Pregnancy. — Chorea, or St. Vitus' 
Dance, Epilepsy, and Insanity are forms of nervous dis- 
orders which sometimes complicate pregnancy. Such 
cases require skilled medical treatment. 

Patients with heart trouble, and those who are con- 
sumptive, also require constant medical supervision, as 
pregnancy has a deleterious influence upon them. Con- 
sumptives sometimes feel better while pregnant, but 
sink rapidly afterward. 

Those diseases which are associated with high temper- 
ature, such as the eruptive fevers and inflammation of 
the lungs, have a marked tendency to bring on the labor 
before time. There is also danger of their inducing 
puerperal septicemia. 

Syphilis is a constitutional disease and a form of 
blood-poisoning which also has an injurious effect upon 
pregnancy. If the pregnancy does not terminate pre- 
maturely, the child is usually born with the taint of the 
disease. 

Jaundice, or icterus, during pregnancy, may be caused 
by the obstruction due to pressure of the gravid uterus 
on the liver. It is sometimes the result of acute yellow 
atrophy, a disease in which the liver wastes away. The 
patient becomes intensely jaundiced and abortion 
often takes place. 

Displacements of the uterus, as prolapse, ante version 



MANAGEMENT OF PREGNANCY. 55 

and retroversion, sometimes complicate pregnancy and 
require careful management by a physician. For pro- 
lapse the wearing of a pessary until the uterus rises into 
the abdomen may be sufficient. The irritability of the 
bladder caused by anteversion in the later months of 
pregnancy may be relieved by the use of an abdominal 
belt, or bandage ; in the earlier months by the recumbent 
posture. Retroversion of the gravid uterus is most 
serious, causing retention of urine and threatened 
abortion. The use of the catheter with replacement of 
the uterus are indicated. 



CHAPTER VI. 

THE EXAMINATION DURING PREGNANCY. 

After missing several periods, the pregnant patient 
usually calls upon her physician to arrange for attend- 
ance in her approaching confinement and is directed to 
report at regular intervals and to send a specimen of 
urine for examination every month. At the first visit or 
subsequently, a complete physical examination is 
made and the pelvis is measured. Four to six weeks 
before the expected date of confinement, the abdominal 
examination is repeated and an internal examination 
is usually made. 

Preparation for the Physician. — Provide towels, a 
basin of hot water, nail brush and soap, a basin of bi- 
chloride solution 1-4000, sterile rubber gloves. While 
the examination is in progress renew the hot water in 
the basin, have ready in a convenient place the pelvi- 
meter, stethoscope, auscultation towel, pencil and 
tablet for taking notes and a yard-stick or tape-line. 

Preparation of the Patient. — The bowels and bladder 
must be empty. In a private home the patient 
should be in bed wearing a nightgown, drawers and 
stockings. In office practice, the patient must re- 
move her dress, long petticoat and corset and must 
loosen every band and string about the waist. 

56 



THE EXAMINATION DURING PREGNANCY. 57 

Place the patient on the bed or table in the recum- 
bent position with a pillow under her head, roll the 
undervest or nightgown up to the armpits and draw 
the skirts and drawers down below the hips. Cover 
the lower extremities with a neatly folded sheet reach- 
ing to the level of the symphysis. 

After examining the heart and lungs, the physician 
notes the size, shape and consistence of the breasts and 
nipples; then proceeds to palpate the abdomen to 
determine the height of the uterus, the relative position 
of the child, and whether the presenting part is engaged 
in the pelvic brim. After locating the child's back, the 
physician listens over it using the auscultation towel or 
stethoscope and counts the rate of the foetal pulse, 
usually keeping the fingers of one hand on the mother's 
radial pulse. 

Pelvimetry. — The following measurements are usually 
taken : 

1. Interspinous. The distance between the anterior 
superior iliac spines — 9 1/2 to 10 1/2 inches. 

2 . Intercristal diameter. The widest interval between 
the iliac crests — 10 1/2 to 11 1/2 inches. 

3. Between the great trochanters. The greatest 
distance between the external surfaces of the great 
trochanters of the femurs— 12 1/2 inches. 

4. The external conjugate. Baudelocque's diameter, 
from the depression just below the last lumbar spine to 
the middle of the anterior surface of the pubic symphysis 
— 8 inches. 



53 



OBSTETRIC NURSING. 



5. Right external oblique. From the right posterior 
superior spine of the ilium to the right anterior superior 
spine — 8 3/4 inches. 

6. Left external oblique. 




ft- - mf 

Fig. 18. — Measuring the Interspinal Diameter With the 
Baudelocque Pelvimeter. 

7. Transverse diameter of the outlet. Between the 
tuberosities of the ischia — 4 1/2 inches. The first two 
measurements are taken with the patient in the dorsal 
recumbent position ; the next two with the patient in the 



THE EXAMINATION DURING PREGNANCY. 59 

left lateral position; the left oblique is taken with the 
patient in the right lateral position and the transverse 
of the outlet with the patient in the dorsal position. 

These external measurements give an idea of the 
general shape and symmetry of the pelvis rather than 
of its exact size. If these measurements are undersize, 
a careful internal measurement must be taken. 

Internal Examination. — After taking the external 
measurements, the physician proceeds to disinfect his 
hands and puts on sterile gloves in preparation for 
the internal examination. Meanwhile, the nurse cleanses 
the patient's vulva, using first sterile water and green 
soap mixture, then bichloride solution 1-10,000 
followed by sterile water. Use absorbent cotton and 
wipe from above downward. 

By internal examination the physician determines 
the height and nature of the presenting part, the con- 
dition of the soft parts and the comparative roominess 
of the pelvic canal. 

Measuring the Internal or Diagonal Conjugate. — This 
is the most important obstetric measurement and is 
taken as follows: Two fingers of the right hand are 
inserted into the vagina, the tips of the middle finger 
resting against the promontory of the sacrum while 
the web of the thumb is closely applied to the under 
surface of the symphysis. The index- finger of the left 
hand marks the point where the lower border of the 
symphysis touches the web of the right thumb and the 
right hand is now withdrawn. The nurse measures 



60 OBSTETRIC NURSING. 

with the pelvimeter the distance thus obtained — nor- 
mally 51/4 inches. By subtracting 3/4 to 1 inch from 
this measurement an accurate idea of the anteropos- 
terior diameter of the pelvic brim is obtained. In con- 
tracted pelves this measurement is of great importance ; 



■;:% 




Fig. 19. — Digital Method of Measuring the Diagonal Conjugate of 
the Pelvic Inlet. {Edgar.) 

indeed, indications for the induction of premature labor 
or for the performance of Cesarean section may be 
based on this measurement alone; in some cases it is 
necessary to etherize the patient in order to determine 
it exactly. 



CHAPTER VII. 

ACCIDENTS OF PREGNANCY. 

A Discharge of Blood from the womb, known as 
"uterine hemorrhage," may occur at any time during 
the pregnancy, and is usually a sign that the patient is 
threatened with a miscarriage. 1 However slight the 
flow, the nurse should have the patient lie down until 
the doctor has 'been told of its occurrence, and decides 
what the patient should do. A note should be sent to 
the doctor, telling just what has happened, and clearly 
making him understand the urgency of the symptoms — 
that is, the amount and character of the flow — and the 
condition of the patient. A nurse should not trust to 
a verbal message, as the physician may fail to respond 
to the call promptly, not being aware of the urgency 
of the symptoms. The patient should be required to 
use the bed-pan, or, at least, a vessel the contents of 
which can be thoroughly examined, both for the bowels 
and the passage of urine. All discharges, soiled cloth- 
ing, clots, etc., should be carefully saved for the in- 
spection of the physician. 

Meantime, an effort should be made on the part of 
the nurse to control the flow. The patient should lie 
with her head low, and a pillow under her hips; she 

1 Such a flow, if excessive, is called an antepartum hemorrhage. 

61 



62 OBSTETRIC NURSING. 

should not be warmly cohered, plenty of cool, fresh 
air should be admitted into the room, and she should 
be keep exceedingly quiet. 

Should the symptoms become more urgent, the 
patient being threatened with fainting, the head may 
be lowered by raising the foot of the bed, placing bricks 
or chairs under it in such a wav as to make a decided in- 
clined plane or bed. The patient should be fanned, given 
hartshorn to inhale, and her limbs rubbed, to keep them 
warm, with alcohol or whisky. Small doses of whisky 
or aromatic spirits of ammonia may be given her in cold 
water, if able to swallow, or black coffee or tea, not too 
warm. If there is much blood flowing from the vulva, 
vaginal injections of hot water, at a temperature of 
about i io° to 1 1 5 , may be kept up until the flow ceases. 
The physician when called may think it best to tampon- 
ade the vagina. For this purpose long strips of steril- 
ized gauze or sheeting may be needed, which the nurse 
should have in readiness. 

Alarming hemorrhages are often the result of acci- 
dents, falls, or blows, or they may be caused by heavy 
lifting. 

Hemorrhage from a Low Attachment of the Pla- 
centa, or afterbirth, or when the afterbirth occupies an 
unusual position — that is, at the side of or over the 
mouth of the womb — occurs without any history of 
accident. It takes place at any time from the seventh 
month of pregnancy on to its termination, and without 
any premonitions of its coming. It may occur at night 



ACCIDENTS OF PREGNANCY. 63 

while a patient is lying in bed. The management of 
this condition would be the same as that described 
above, until the doctor comes. 1 

Hemorrhage from Varicose Veins. — Women suffering 
from enlarged, swollen veins, "varicose veins," or 
" varices,' ' of the lower extermities, if not careful in 
keeping the limbs bandaged or supported by elastic 
stockings may have hemorrhage occur by the bursting 
of one of these overdistended veins. The amount of 
blood lost may be so great as to imperil the patient's 
life. Should such a rupture of a vessel occur, compres- 
sion should be made just below the point of rupture, to 
control the bleeding, until the physician, who should 
have been sent for, arrives, when he will resort to the 
measures necessary for securing against further 
hemorrhage. 

Miscarriages are apt to recur, hence a patient who has 
once suffered from one should be cautioned to take ad- 
ditional care of herself during any subsequent pregnancy. 
Any sensation of weight about the hips, with the recur- 
rence of a "show," or slight discharge of blood, and 
cramp-like pains should warn her to lie down and send 
for her physician. Such a patient should also take the 
precaution to lie down as much as possible (if not in bed, 
on a lounge) during the time when, under other cir- 
cumstances, she would have her monthly flow. Any 

Rupturing the membranes is often the only way to check an antepartum 
hemorrhage, due to these causes. Sometimes version of the child is per- 
formed and a limb brought down in such a way as to make pressure against 
the detached placenta. 



64 OBSTETRIC NURSING. 

patient having had a number of miscarriages should 
keep herself under the care of her physician from a very 
early date in the pregnancy, being placed under a reg- 
ular course of treatment. 

It is well, in this connection, to speak of the impor- 
tance of care in the after-treatment of miscarriages. 
Not uncommonly, patients, especially of the working 
classes, get up and go about their work a day or two 
after the occurrence. This is a dangerous proceeding, 
for, though the ill effects may not be felt for a time, 
chronic disease of the uterus is apt to result. If the 
pregnancy terminates before the fourth month it is 
commonly called an abortion. Between the fourth and 
seventh months it is a miscarriage, and after the seventh 
month, if before term, a premature labor. 

It is really necessary to give more time to the recov- 
ery from the effects of an abortion than to recovery 
from a confinement at term, and the patient should be 
willing to remain in bed at least a week or ten days, or 
longer, if thought best by her physician. The patient 
should not leave her bed as long as any discharge 
of blood continues. 

The causes of abortion may depend on some disease of 
the ovum or embryo, or it may depend on the mother. 
A frequent cause is the pouring out of blood between 
the two layers of the decidua. When this bleeding 
occurs low down, near the os uteri and is slight, abortion 
may not follow. When there is more blood and especi- 
ally if it occurs nearer to the fundus of the uterus, the 



ACCIDENTS OF PREGNANCY. . 65 

blood forms a clot and serves to separate the ovum 
from its attachment to the uterus, thus causing abortion. 
When the ovum is expelled with the freshly formed clots 
around it, it is called a blood mole; when, however, it is 
retained for some time in the uterus and undergoes a 
change into a fleshy mass, it is called a flesh mole. 
Sometimes abortion is caused by degeneration of the 
chorion into a grape-like mass of small vesicles. This 
is called hydatidiform degeneration of the chorion, and 
constitutes a bladder mole. It commences at an early 
period of the pregnancy and almost always causes the 
death of the embryo. The enlargement of the uterus 
does not follow the regular progress that it does in nor- 
mal pregnancy, and irregular bloody discharge from 
the uterus, containing some of these little bladders will 
arouse the suspicion as to the condition which exists. 
The uterus should then at once be emptied. 

Fatty degeneration or fibrous degeneration of the 
placenta, the causes of which are not certainly known, 
also often result in abortion. 

Other causes, such as fright, extreme nervousness, 
excessive coitus, fevers, poisonous conditions of the 
blood, as in syphilis, lead poisoning, carbonic acid 
poisoning, etc., are very numerous. 

When it is impossible to prevent an abortion, the 
sooner the uterus is emptied the better. If the os uteri 
is well dilated, this may easily be accomplished by in- 
troducing the finger, after thorough sterilization of the 
hands, and detaching the ovum, and drawing it out. 
5 



66 OBSTETRIC NURSING. 

It is best always for a physician to assume the respon- 
sibility of this. When there is not enough dilatation, it 
can often be aided by plugging the vagina with strips 
of antiseptic gauze. This is best done through a 
speculum. 

One of the most dangerous forms of abortion is when 
only a portion of the ovum has been expelled. This is 
called an incomplete abortion. Two dangers arise from 
this : septicemia, or blood-poisoning from decomposition 
of the portions of the ovum and placenta retained; 
and hemorrhage which may occur frequently as long as 
the uterus remains unemptied. The treatment required 
is to dilate the uterine os under chloroform or ether, 
and to carefully remove all that remains of the ovum. 

Sometimes a small portion of retained placenta forms 
a kind of polypus and is called a placental polypus, its 
attachment to the uterine wall being quite firm. It 
will need removal as any other form of uterine polyp. 

Certain drugs, such as ergot, cannabis indica, savin, 
quinine, etc., called oxytocics, have the power to cause 
the uterus to contract and may cause abortion. They 
should, therefore, be avoided during pregnancy. 

Premature Rupture of the Membranes enclosing the 
child, with a discharge of colorless liquid, commonly 
known as " breaking of the waters," is another of the 
accidents of pregnancy, and is invariably followed, 
within a few days, at least, by the expulsion of the 
child. The patient will complain of her clothing be- 
coming wet, either by a sudden discharge of a quantity 



ACCIDENTS OF PREGNANCY. 67 

of liquid, or by a slow but continuous flow. The nurse 
can assure herself that this liquid is not urine by her 
sense of smell. The smell of urine is characteristic. 
With the amniotic liquid surrounding the child, there 
is almost an entire absence of smell, a peculiar, faint, 
musty odor alone being recognizable. 

It is best, in removing this wet clothing from the 
patient, to set it aside, that the physician may judge 
for himself of the character of the liquid. The patient 
should at once lie down, not taking the erect position 
for any cause, not even for defecation and urination, and 
the physician should be sent for, with a written state- 
ment as to what has occurred. It is important that 
the physician should see the patient as soon after the 
rupture of the membranes as possible, because the sud- 
den loss of water may have brought about changes in 
the position of the child which may endanger its life. 
The loss of the entire amount of liquid contained in the 
sac would cause also difficulties in the delivery, or 
what is known as "a dry labor." 

Convulsions, or eclampsia, may sometimes occur dur- 
ing the pregnancy. The symptoms which threaten 
this trouble are extreme restlessness and uneasiness on 
the part of the patient ; diminution in quantity of urine 
passed, severe headache, often confined to one side of 
the head; disorders of vision, as seeing things double, 
or seeing but the part of an object, sometimes very im- 
perfect vision, and occasionally absolute loss of sight; 
twitchings of the muscles, especially of the face, may 



68 OBSTETRIC NURSING. 

occur. The convulsion is ushered in by this restless- 
ness and twitchings, beginning first about the eyes 
and extending rapidly to the mouth, arms, and lower 
extermities. The movements are not violent, hence 
the patient is not likely to throw herself out of bed. 
During the convulsion the tongue may be bitten 
and the lips covered with blood-stained mucus; spasm 
of the diaphragm results in arrest of breathing and 
marked cyanosis. After one or two minutes' duration the 
muscular spasm relaxes, the convulsion terminates in 
a long inspiration and the patient passes into a state 
of coma. She lies unconscious, with flushed face, 
snoring respiration, full pulse, and elevated temper- 
ature. This state may last an hour or more, the pa- 
tient gradually regaining consciousness if treatment 
has been successful or, if otherwise, repeated convulsions 
occur during one of which the patient may die or in 
some cases death results from oedema of the lungs. Upon 
the first onset of eclamptic symptoms the physician 
should be sent for meantime, the nurse should see 
that the patient is kept lying down, that her cloth- 
ing is well loosened, especially about the head and chest, 
that plenty of fresh air enters the room, and that the 
patient is kept from biting her tongue. A folded hand- 
kerchief or towel slipped in between the teeth pushes back 
the tongue and prevents the teeth from coming down 
upon it. False teeth should be removed, the room 
should be darkened and sudden noises, loud talking 
and jarring of the floor or bed must be prevented. 



ACCIDENTS OF PREGNANCY. 69 

The patient's feet should be kept warm and head cool. 
The members of the family must be kept calm and pre- 
vented from meddlesome interference, for the attempt 
to make the patient swallow any stimulant while 
struggling and unconscious may result very disastrously. 
Should the attending physician live too far away or 
be delayed in coming, the nearest physician should be 
sent for. 

Eclampsia is caused by some organic poison produced 
during pregnancy and imperfectly eliminated, as a rule 
because of kidney disease. Treatment is directed 
toward eliminating the poison and terminating the 
pregnancy. Three avenues of elimination are available 
— the skin, intestines, and kidneys. Hot packs stimulate 
copious elimination by the skin. 

Method of giving a Hot Pack. — Under the patient 
place a rubber blanket covered by a wool blanket, 
arrange four hot-water bottles or four hot bricks 
wrapped in bath towels on each side of the patient far 
enough away from her to avoid any possibility of burning , 
then cover all with a second wool blanket and rubber 
blanket. Put an ice-bag to her head and watch the 
pulse and respiration; if the pulse becomes feeble or 
irregular or the respirations shallow the pack must be 
discontinued, but if well borne the patient may remain 
in it for thirty minutes after sweating begins. At the 
end of this time remove the rubber blankets, bricks or 
bottles, sponge the patient off with warm alcohol and leave 
her between dry blankets. Such a pack may be re- 



7<D OBSTETRIC NURSING. 

peated once in three or four hours ; in the intervals be- 
tween packs salt solution is administered continuously 
by rectum or subcutaneously and hot flaxseed poultices 
are applied to the kidney region . 

To empty the bowels one drop of croton oil is given 
in a few drops of olive oil placed well back on the patient's 
tongue or 10 grains of calomel are placed dry on the 
tongue. 

As soon as possible the physician ruptures the mem- 
branes ; this causes a sudden fall in blood pressure and 
stiniulates uterine contractions which, under the in- 
fluence of the hot packs, usually result in spontaneous 
delivery within a few hours; otherwise, resort must be 
had to some form of operative delivery. 

Blood-letting is sometimes necessary to relieve ex- 
cessive arterial tension; nitroglycerine or veratrum 
viride are given for the same purpose. Chloral or 
chloroform may be used to control the spasm and oxy- 
gen inhalations are useful during coma. The patient's 
lips must be wiped off frequently with gauze wet 
in listerine or boric acid solution. 



CHAPTER VIII. 

THE ANATOMY OF THE FCETAL HEAD AND THE MECHANISM 

OF LABOR. 

The foetal head is the part of the child's body which, 
in a natural labor, is expelled first. It is the firmest and 
most resistant part, and where it passes the rest of the 
body easily follows. 

The bones of the foetal skull are usually considered 
under two heads, those composing the cranium or vault 
of the head and those of the face and under surface of 
the skull. 

The bones of the vault are as follows : One frontal, or 
forehead bone ; two parietal or side bones ; one occipital 
bone, at the back of the head; two temporal bones, one 
sphenoid, and one ethmoid. The last two mentioned 
are of no especial importance obstetrically consideied. 

In the face there are fourteen bones; but these also 
are not of obstetrical value. 

The bones of the vault are joined together by carti- 
lage so that when pressed together in labor the size of 
the head is diminished and it is allowed to pass through 
the pelvis with greater ease. 

The lines of union between these bones are called 
sutures. The most important of these are : 

7i 



72 OBSTETRIC NURSING. 

i . The coronal suture between the frontal and parie- 
tal bones. 

2. The sagittal suture running from the posterior 
angle of the bregma (or large fontanelle) to the lamb- 
doidal suture at its junction with the posterior fonta- 
nelle. 

3. The lambdoidal suture, between the occipital 
bone and the parietal bones posteriorly. 

These three are the sutures which it is most important 
to be able to recognize by touch, as they may be reached 
most readily during labor by the examining finger. 

4. The frontal suture is the division down the mid- 
dle of the forehead between the two parts of the frontal 
bone. 

5. The two temporal sutures, one on each side, are 
the lines of separation between the temporal and parie- 
tal bones. 

The fontanelles are membranous spaces between the 
cranial bones where the sutures meet. The most im- 
portant are: 

1. The anterior or greater fontanelle. 

2. The posterior or lesser fontanelle. 

The anterior fontanelle is lozenge-shaped and about 
large enough to be covered by the tips of two fingers. 
Four sutures terminate in it; the two halves of the 
coronal suture, the sagittal suture, and the frontal 
suture. It is the only fontanelle having four sutures 
meet it. 

The posterior fontanelle is not always a membranous 



THE ANATOMY OF THE FCETAL HEAD. 



73 



space. Here three sutures meet: the two portions of 
the lambdoidal and the posterior extremity of the sagittal. 
There is another triangular-shaped fontanelle which 
may be felt at the side of the head called the posterior 
temporal fontanelle. This may be distinguished from 
the posterior fontanelle by its close proximity to the ear. 
It is necessary to take certain measurements or diam- 
eters of the foetal head in order to compare them with 




Fig. 20. — The Fcetal Skull (Diameters). 
of. Occipito-frontal. om. Occipito-mental. xm. Maximum, 
cipito-bregmatic. tb. Trachelo-bregmatic. ym 



bs. Suboc- 
Fronto-mental. 



the diameters of the pelvis. The average size of the 
foetal head is thus determined. When the head is too 
large there is difficulty in its passing through the pelvis. 
The most important diameters are the following : 
1. The occipito-frontal (written O. F.), the distance 
between the center of the frontal bone, at the root of 
the nose, and the upper part of the occiput. It meas- 
ures about 41/2 inches. 



74 OBSTETRIC NURSING. 

2. The occipito-mental (O. M.), the distance between 
the middle of the chin and the upper part of the occipi- 
tal bone. It measures about 5 to 5 1/2 inches. 

3. The bi-parietal (B. P.), between the two parietal 
eminences, about 3 1/2 or 4 inches. 

4. The bi-temporal (B. T.) between the two temples 
— about 3 inches. 

The occipito-mental is the longest of the foetal diam- 
eters, excepting when the head has been so moulded 
during labor that its shape has been changed by the 
pressure of the bones of the pelvis. The longest diam- 
eter after labor is called the Maximum diameter (M.), 
and extends from the point of the chin to a variable 
point on the back of the head. It measures about 
51/2 inches. 

The head of the child may be safely compressed to 
a certain extent from side to side, but not from be- 
fore backward. When there has been much delay in 
the birth and much pressure from the pelvic bones, 
the child's head often seems quite distorted in shape. 
No effort should be made to press it into shape 
again. In a few days it will return to its normal 
shape. 

The mechanism of labor consists in the movements 
made by the presenting part of the child (usually the 
head) in its passage through the pelvic canal. 

For a normal mechanism the foetal head should be of 
a proper size to fit the pelvis through which it has to 
pass. 



THE ANATOMY OF THE F(ETAL HEAD, 



75 



The foetal head may enter the pelvis in four different 
positions, as follows : 




Fig. 21. — Left Occipitoanterior Position. 




Fig. 22. — Right Occipito-anterior Position. 

i. Left occipito-anterior (L. O. A.), the occiput or 
vertex being directed toward the left acetabulum or 
socket of the hip joint. 



76 



OBSTETRIC NURSING. 



2. Right occipito-anterior (R. O. A.), the occiput 
being directed toward the right acetabulum. 




Fig. 23. — Right Occipito-posterior Position. 




Fig. 24. — Left Occipito-Posterior Position. 



3. Right occipito-posterior (R. O. P.), the occiput 
being directed toward the right sacro-iliac articulation. 



THE ANATOMY OF THE FOETAL HEAD. 77 

4. Left occipito-posterior (L. O. P.), the occiput 
being directed toward the left sacro-iliac articulation. 

Some obstetricians consider the third position to 
rank second in frequency of occurrence. In both the 
first and third positions the sagittal suture of the child's 
head lies in relation with the right oblique diameter of 
the pelvic inlet, and should be felt by the examining fin- 
ger. In the first position the posterior fontanelle is di- 
rected forward, the anterior fontanelle being back- 
ward. These positions are reversed in the third posi- 
tion of the head. In the second and fourth positions 
the sagittal suture lies in relation with the left oblique 
diameter. 

In its passage through the pelvis the head undergoes 
certain movements as follows : 

1. Flexion with Descent, the child's head being bent 
forward so that its chin rests upon its chest ; at the 
same time that the head descends into the pelvic canal. 

2. Internal Rotation — the occiput moving toward 
the anterior part of the pelvis until it finally becomes 
fixed under the pubic arch. 

3. Expulsion with Extension of the Head. 

4. External Rotation, or Restitution, the occiput 
being again directed toward the side of the pelvis 
it originally occupied. This occurs outside the pelvis, 
while the body of the child is turning inside the pelvis 
in such a way as to accommodate the shoulders in the 
antero-posterior diameter of the outlet. 

In consequence of obstructions to the passage of the 



78 OBSTETRIC NURSING. 

head into the pelvis, irregular mechanisms are sometimes 
brought about and the labor is rendered abnormal. A 
physician should always be at once notified when there is 
any complication of this kind observed. The occiput 
meeting with some resistance, may be held at the brim 
and the uterine contractions acting through the spinal 
column of the child, may force down the anterior part 
of the child's head. In this way brow or forehead 
presentations and face presentations occur. 

In brow presentations the anterior fontanelle, the fore- 
head and the ridges above the eye sockets are felt by 
the examining finger. The head cannot be born in 
this position, which must be changed so that the occi- 
put or the face comes down. 

In face presentations the extension of the head is more 
extreme and the examining finger reaches the nose, 
mouth and chin of the child. 

Face presentations are named from the direction to- 
ward which the chin points. From the Latin word sig- 
nifying "chin" these are termed mental presentations, 
as follows : 

i. Right mento-posterior (R. M. P.) in which the 
chin is directed toward the right sacro-iliac articulation. 

2. Left mento-posterior (L. M. P.) in which the chin 
is directed toward the left sacro-iliac articulation. 

3. Left mento-anterior (L. M. A.) in which the chin 
points to the left acetabulum. 

4. Right mento-anterior (R. M. A.) in which the 
chin points to the right acetabulum. 



THE ANATOMY OF THE FCETAL HEAD. 



79 



Face presentations occur once in about 230 births. 
In the majority of cases the delivery in face presenta- 
tions may be accomplished without any operative inter- 
ference. The mechanism is similiar to that which occurs 
in occiput or vertex presentations excepting that the chin 




Fig. 25. — Presentation of the Face in the Second Facial Position. 



rotates to the anterior portion of the pelvis, in place of 
the occiput ; and the head is expelled by a movement of 
flexion instead of extension; by this means the occiput 
sweeps over the perineum instead of the face, as in 
vertex presentations. The labor is always a prolonged 
one and the membranes are apt to be ruptured pre- 



80 OBSTETRIC NURSING. 

maturely because of the irregular shape of the present- 
ing part. Sometimes also the cord becomes prolapsed. 
These facts all add to the danger of the child during 
the birth. The mother suffers from the long-continued 
pressure on the pelvic tissues and the perineum is very 
apt to be badly torn because of the way in which the 
head is expelled. 

The rotation of the occiput into the hollow of the 
sacrum and the rotation of the chin in the same way 
always require operative interference, excepting in cases 
where there is practically no mechanism of labor be- 
cause the pelvis is large and the child's head small and 
expulsion takes place rapidly. 

When there is difficulty or too long delay in the birth 
in head presentations, the use of forceps may be called 
for and the nurse will need to have everything in readi- 
ness. 

Caput succedaneum is a term applied to the puffy 
swelling which appears on some part of the child's head 
during labor by an effusion of serum under the scalp. 
It is caused by the pressure of the os uteri in the first 
stage of labor and by the pressure of the pelvis during 
the second stage. Its situation varies with the position 
of the head. After birth it rapidly disappears because 
pressure is removed. Its presence often interferes 
during labor with the examiner's efforts to learn the 
exact position of the head. 

Pelvic presentations are of three varieties: breech, 
knee, and foot (called footling) . 



THE ANATOMY OF THE FCETAL HEAD. 8 1 

The breech presentation is the most common of these 
because of the attitude which the foetus normally occupies 
in the uterus. 

By the attitude of the foetus we mean the relation 
which the foetal parts bear to each other. 




Fig. 26. — Breech Presentation, the Legs Extended. 

The usual position of the child is with the knees drawn 
up toward the abdomen and the heels close to the nates, 
the feet being flexed upward toward the legs. The 
child's head is bent forward on the chest, the arms are 
crossed over the breast. The breech of the child in this 
position is most readily felt by the examining finger, 
6 



82 OBSTETRIC NURSING. 

when it presents at the inlet and may be recognized by 
feeling the tip of the coccyx, the anus, and the genitalia. 
Sometimes the feet can be felt at the same time . Occasion- 
ally the child's thigh becomes stretched out and a foot 
comes down lower than the breech. This constitutes a 
footling presentation. It is more frequent than the 
knee presentation, which is produced by the leg becom- 
ing bent backward so that the knee presents at the os 
uteri. 

In a large number of pelvic presentations labor oc- 
curs prematurely and there is little difficulty in the 
mechanism. 

The breech may present in two ways ; either with the 
back turned forward (dorso-anterior) ; or the back 
turned toward the mother's back (dorso-posterior). 
The dorso-anterior positions are the most common. 

By external examination pne may discover a breech 
presentation by feeling the head of the child, like a hard 
ball, through the abdominal walls, in the upper part of 
the uterus. 

The different positions of the breech at the inlet have 
been named, as follows : 

i. Left dorso-anterior (L. D. A.). The examining 
finger here discovers the posterior surface of the sacrum 
directed toward the left acetabulum. 

2. Right dorso-anterior (R. D. A). The posterior sur- 
face of the sacrum is directed to the right acetabulum. 

3. Left dorso-posterior (L. D. P.), the sacrum di- 
rected to the left sacro-iliac articulation. 



THE ANATOMY OF THE FOETAL HEAD. 83 

4. Right dorso-posterior (R. D. P.), the sacrum 
directed to the right sacro-iliac articulation. 

Positions of knee and footling presentations are deter- 
mined in the same way. The position of the heels of the 
child will enable the position of the sacrum to be decided 
in any footling presentation. 

The movements, or mechanism of labor in a breech 
presentation are as follows : 

1 . Compression with descent of the breech into the 
pelvis. 

2. Internal rotation until the anterior thigh is 
brought under the pubic arch. 

3 . Expulsion of the posterior thigh first followed by 
that of the anterior thigh and the trunk as far as the 
shoulders. 

4. Fixation of the anterior shoulder under the pubic 
arch. 

5. Expulsion of the posterior shoulder first followed 
by that of the anterior shoulder. 

6. External rotation of the body with the back look- 
ing upward — at the same time internal rotation of the 
head. 

7. Fixation of the nape of the neck under the pubic 
arch. 

8. Expulsion of the head by a movement of flexion, 
the face and vault sweeping over the perineum, while 
the body of the child is extended up toward the 
mother's abdomen. 

All breech deliveries are apt to be tedious and there is 



84 OBSTETRIC NURSING. 

a temptation to hurry them by seizing the legs and thus 
extracting the child. 

This is very dangerous, for if the legs are seized and 
the body rapidly drawn down the chin is drawn away 
from the chest and the result may be a malposition of 
the af tercoming head ; or the arms may be drawn away 
from the chest and extended. These accidents cause 
delay of the head in the pelvis and pressure on the cord 
and often cause the death of the foetus. 

In every labor, in a breech presentation, the greatest 
danger comes after -the shoulders are born — while the 
head is still in the pelvic cavity. Up to that time the 
attendant on the labor is required to do nothing, unless 
it be simply to draw on the cord a little to loosen it, if it 
seems to be pulled on too much during the expulsion of 
the body. 

Assistance usually needs to be given, however, in ex- 
traction of the head for the child is in great danger of 
suffocation, if there be the least delay. To effect this, 
the fingers of one hand may be hooked over the shoulders 
of the child, while the fingers of the other are introduced 
into the mother's vagina and a hold obtained by them in 
the child's mouth or on each side of its nose. The body 
of the child may ride the operator's arm. The head is 
then by gentle traction drawn out in the same manner in 
which it would be naturally expelled. 

Knee and footling presentations have practially the 
same mechanism as the breech and the rules for manage- 
ment are the same. 



THE ANATOMY OF THE FOETAL HEAD. 85 

Transverse presentations are those in which the long 
diameter of the child lies in relation with the transverse 
diameter of the uterus. These are sometimes called 
shoulder or arm presentations because the shoulder or 
arm almost always is, sooner or later, forced down into 
the pelvis. In these there is much danger both to 




Fig. 27. — Presentation of Right Shoulder. 

mother and child, especially when the presentation is 
not recognized before the membranes rupture. If 
recognized early, this malpresentation may be converted 
into a mormal one by version, or turning. 

There are two principal varieties of transverse presen- 
tations. In the first, the child's back is forward to- 
ward the mother's abdomen (dorso-anterior) ; in the 
second it is turned backward, towards the mother's 



86 OBSTETRIC NURSING. 

back (dorso-posterior) . The dorso-anterior positions 
are much the most frequent. 

The child's head lies in either the one or the other 
iliac fossa, and either the right or left shoulder may pre- 
sent at the inlet. 

This gives us four positions in shoulder presentations 
as follows : 

i. Dorso-anterior position of the right shoulder. 

2. Dorso-anterior position of the left shoulder. 

3. Dorso-posterior position of the right shoulder. 

4. Dorso-posterior position of the left shoulder. 

By external examination the transverse presentation 
may be recognized from the shape it gives the abdomen 
which will be wider across than in its longitudinal diam- 
eter. The head of the child may also be recognized in 
one or other side of the abdomen. By internal exami- 
nation the absence of the head at the inlet will be noted. 
When the os begins to dilate the pouch of membranes 
will take on an elongated sausage-like form. After the 
membranes have ruptured, the shoulder, the elbow, or 
the head may be felt ; also the ribs may be recognized. 

The transverse presentation must always be changed 
before delivery can be effected. Even without artificial 
aid, nature makes an effort to change the presentation 
by the action of the uterine contractions, and to termin- 
ate the labor either by spontaneous version or sponta- 
neous evolution. 

In spontaneous version the presentation is changed 
to the breech or the head. 



THE ANATOMY OF THE FCETAL HEAD. 87 

In spontaneous evolution the foetus is driven through 
the pelvic canal, the head remaining above the brim and 
the body of the child becoming doubled up and thus 
pushed through the pelvis with the arm still presenting. 
The child is, of course, born dead, and the injury which 
the mother suffers from the hard labor may cause her 
death. 

The proper treatment, therefore, is to perform version 
early; converting the transverse presentation into a 
breech or vertex. 



CHAPTER IX. 

PREPARATIONS FOR THE LABOR. 

The relations between nurse and patient begin from 
the time the engagement is made for a nurse's attend- 
ance upon the confinement. 

The nurse is generally consulted beforehand as to the 
articles that will be needed at the time of the confine- 
ment and for the baby's outfit. Also, she is sometimes 
asked concerning the choice of a room for the labor and 
lying-in. 

The room is a most important consideration. It 
should be light, having free entrance of sunlight, quiet, 
and well ventilated. It should be kept at a tempera- 
ture of 70 in winter. 

The Mother's Dress. — She should be advised to have 
a sufficient number of good-sized merino or flannel 
vests, to be able to change night and morning, so 
that the same vest shall not be worn both day and 
night. These are more readily changed if opened all 
the way down the front and fastened with tapes. The 
free action of the skin after delivery necessitates the use 
of flannel or merino to prevent chilling. If a long night- 
dress is worn, there is no necessity for the chemise. The 
night-dress, also, should be opened all the way down the 
front, as it renders easier for the patient the frequent 

88 



PREPARATIONS FOR THE LABOR. 



8 9 



changes which are necessary. Sufficient night-dresses 
and vests should be provided to make it possible for the 
clothing to be changed every day. 

Two or three abdominal bandages, also, should be pro- 
vided, either fitted to the patient's person or straight. 
If fitted, the bandages should be prepared when the 



/ 



?S$ 



/6%i 




Fig. 28. 



patient is about six months pregnant, to be the right 
size after delivery. The bandage should extend from 
the pubic bone (the bone just above the external genera- 
tive organs) to the breast-bone, being about a half- 
yard wide and long enough to go once around the body 
and overlap one-third. It is best made of soft muslin 



90 OBSTETRIC NURSING. 

doubled, the seams being turned in at the edges. Large 
safety pins should be provided for fastening this band- 
age down the front. 

Where the breasts are large and pendulous, some 
bandage will be required for their support. A diagram 
of the breast binder used in the Woman's Hospital 
is shown in Fig. 28. These are made of two thicknesses 
of muslin, turned in along the edges and stitched to- 
gether. Two breast binders should be prepared. 




Fig. 29. — Occlusion Dressing. (Garrigues.) 

When the physician does not require the aseptic 
dressings, now almost universally used, at least two 
dozen napkins of diaper linen should be provided for the 
mother, as very frequent changes of the napkin are 
essential during the first few days after the delivery, 
while the discharges are free. The napkins should be 
baked before they are used. 

The aseptic dressings used in the Woman's Hos- 
pital of Philadelphia consist of absorbent cotton pads 
ten inches by three and two inches thick, wrapped in 



PREPARATIONS FOR THE LABOR. 9 1 

pieces of absorbent gauze twenty inches square. These 
are wrapped in packages and sterilized by steam on 
three successive days. In private practice, three 
dozen should be prepared, wrapped in towels or old 
muslin in packages of six and baked in an ordinary 
oven for one hour. 

When removed they should be kept enclosed in the 
towel without opening until required for use. 

The dressing is tightly fastened to the abdominal 
bandage, both anteriorly and posteriorly, by means of 
safety-pins, and the access of air to the vagina is thus 
prevented. They are changed at least once in three 
hours, the dressing removed being at once burned. It 
is seldom necessary to continue the dressings longer 
than two weeks. They should be kept up, however, so 
long as the discharge persists. 

After the above statement, it will be seen that a 
nurse should have the patient obtain twelve yards of 
cheese cloth and two pounds of absorbent cotton. 

In winter it is well for the mother to be provided with 
a woolen bed sack. 

For the confinement bed the patient should provide 
two pieces of rubber-cloth, a yard and a half square. 
For a single bed two rubber army blankets may be used, 
if, as in the maternity practice in the Woman's Hospital, 
it is desired to cover the whole bed. The arrangement 
of the bed will be explained in a later chapter. White 
rubber gum-cloth is the best when it is obtained in the 
piece. If the patient is poor, table oil-cloth may be 



92 OBSTETRIC NURSING. 

used ; it- is cheaper and answers the purpose as well ; or 
layers of newspapers tacked together will make very 
good temporary pads. 

A piece of floor oil-cloth is the best protection for the 
carpet at the side of the bed. 

Rubber-cloth should never be used but for one con- 
finement. The rubber cracks when folded and put 
away, and no longer serves its purpose of protecting the 
bed. Then, too, it is very important to be sure that 
everything about the confinement bed is perfectly 
fresh and clean. Hence a rubber-cloth used for con- 
finement should neither be borrowed nor lent. 

Sleeping on rubber-cloth makes a person perspire, 
hence it is desirable to get rid of it as soon as one can. 
It is seldom necessary to use it after the fifth or sixth 
day. 

Other articles necessary to have on hand will be half 
a dozen old sheets, about a dozen towels, a new syringe 
(a fountain syringe, large size, is the best), a bed-pan 
(square pattern), nail-brush, white Castile soap, a jar of 
cosmolin or vaselin, a bottle of antiseptic tablets (corro- 
sive sublimate) , one pound absorbent cotton, two yards 
of nursery cloth, two papers of large safety-pins, one 
paper of small safety-pins, four ounces tincture of 
green soap, four ounces of brandy, one pint of olive 
oil, two half-pound cans of ether. 

I desire, in this connection, to emphasize the fact 
that the syringe should be a new one. This is an anti- 
septic precaution. Hence advise the patient strongly 



PREPARATIONS FOR THE LABOR. 93 

against the use of any syringe which may have been 
used for other purposes, however well it may work. 
Of course, the borrowing of such an article from a 
neighbor or friend should be strongly discountenanced. 

The Baby's Clothes.— If they are made too elaborate 
they will not be washed often enough, hence they should 
be plain. As the depressing influences of cold are very 
injurious to babies, the clothing should be warm, hence 
a flannel garment with long sleeves and high neck should 
be worn next the skin, the thickness varying with the 
season of the year. The activity of the life-processes 
makes it important that every organ of the body should 
be unimpeded in its action and free from pressure, hence 
the clothes should be very loose and light in weight. 

The only articles absolutely needed to constitute an 
outfit are: i. a soft flannel shirt, with high neck and 
long sleeves, opened in front. This is better than the 
merino vests or the knit shirts, which shrink on washing, 
and are then difficult to put on and take off. 2. A 
binder, or bandage of fine, soft flannel, six inches wide, 
and long enough to go around the abdomen once and lap 
over about one-third (22 inches long). This should be 
made without a hem, the raw edge being over stitched to 
prevent raveling. The binder is best fastened by means 
of two pieces of tape attached to one of its edges. 

This arrangement does away with the necessity for 
pins in fastening the binder, the pieces of tape being 
simply wound around the body to secure the binder, 
and tucked in at one edge. Some prefer the knitted 



94 OBSTETRIC NURSING. 

wool band, made of single zephyr and knitted in the 
ribbed stitch, as wristlets or mittens are often knit, to 
permit of greater elasticity. These bands are made a 
little narrower in the center than at either extremity, so 
as to be held in place better. They are made perfectly 
circular, just like a wristlet, and are so elastic that they 
can readily be drawn up over the limbs and adjusted to 
the body. 3 . A napkin of cotton or linen diaper is the 
best ; Canton flannel makes a very poor baby's napkin, as 
it becomes stiff when washed. Napkins are generally 
made too large for a new-born baby, and require to be 
folded into too many thicknesses. A napkin which when 
folded once is half a yard square, is of ample size. The 
number of napkins supplied should be generous, so as to 
permit of frequent washing and thorough airing. Nap- 
kins should always be fastened by safety-pins. For the 
protection of the outer garments from dampness due to 
frequent urination, it is well to have a second napkin 
folded and laid beneath the baby's hips. The use of 
rubber-cloth over the napkin for this purpose is much to 
be condemned, as it overheats the parts and makes the 
skin tender. 4. A flannel slip of heavier or lighter tex- 
ture, according to the season, serves the purpose both of 
petticoat and dress. This should be made just long 
enough to cover the baby's feet — about twenty-five 
inches from neck to hem, and should be fastened in front. 
The ordinary fashion of making a baby's clothes very 
long is objectionable because of the greater weight of the 
clothes preventing free movements of the child's limbs 



PREPARATIONS FOR THE LABOR. . 95 

and the development of its muscles. The object of 
fastening the clothing in front rather than in the back is 
to avoid the necessity of the baby's lying on the uneven 
surfaces produced by buttons, tapes, and hems, which 
no doubt are often a source of discomfort to its tender 
skin. 5. Knit woolen socks are necessary to keep the 
baby's feet warm, and it is well to have them extend 
pretty well up the leg, reaching even to the knee, as cold 
feet are often an exciting cause of colic. 

The above are the only essential articles of clothing 
for a baby. Should the mother prefer, for the sake of 
effect, to see her baby in white muslin, a slip of muslin 
can be worn over the flannel slip. These garments do 
away with all waistbands and the constriction of the 
chest thereby induced. Should the garments be made 
with waistbands, they should be supported from the 
shoulders by means of straps, or armholes should be 
made in the bands, just as in the case of an older child ; 
they will not need then to be drawn so tightly around 
the child to be retained in place. 

A heavy blanket is not needed to wrap the baby in, in 
a room at the temperature of the lying-in room — from 
68° to 70 ; but should it be carried from one room to 
another, or when it sleeps, a blanket, or some wrap, 
ranging in weight with the season, will need to be 
thrown over it. 

When a baby has but little hair on its head, and shows 
a tendency to catch cold readily, a plain cambric or 
light flannel cap may be employed as a head covering. 



96 OBSTETRIC NURSING. 

This is a preventive against catarrhal troubles affecting 
the nose and throat. 

An outfit for babies which has obtained much favor 
among mothers is called the il Gertrude Suit" and con- 
sists of three garments: The first, or undergarment, is 
made of soft flannel, and is long enough to extend 
from the neck to ten inches below the feet. The next 
garment, cut in the same way, but half an inch larger 
and five inches longer, is made of muslin. Over these 
comes the "slip," also Princess style, and the only one 
of the garments with long sleeves. (This is the most 
objectionable feature of the suit; a baby's arms should 
be well covered.) It has a longer skirt than either of 
the other garments. All are fastened behind by small 
buttons. These three garments are put together and 
all slipped on to the baby at one time, facilitating the 
process of dressing very much. 

In our opinion, however, this suit has not the same 
advantage as that worn in the Maternity of the Woman's 
Hospital of Philadelphia, and first described. The 
fastening of the clothing in front, the fewer number of 
articles comprising the wardrobe, and the fact that they 
may be very easily taken off and put on, while they 
meet all the requirements of warmth, looseness, and 
lightness, make this outfit preeminently a comfort to 
the baby. 

It is well to provide a lap-protector for the mother or 
nurse who shall have the baby in charge. This may be 
made of any thick wash material, and if shaped like a 



PREPARATIONS FOR THE LABOR. 97 

pillow-case, and fastened at one end by buttons, a piece 
of rubber sheeting can be slipped inside of it. The rub- 
ber can be slipped out and the case washed as often as 
necessary. 

The articles provided for the baby-basket may be the 
following : — 

Three or four pieces of linen bobbin, about eight inches 
long. 

A pair of blunt-pointed scissors. 

Large and small safety-pins. 

Several small squares of soft linen, about four inches 
square, for dressing the cord, and two inches square, for 
washing the eyes and mouth. 

A soft hairbrush. 

A powder-box and puff, with lycopodium or fine 
starch powder, or plain talcum. (The scented powders 
are often irritating.) 1 

A small jar of cold cream. 

Two soft towels. 

A full suit of clothes, as described above, for the baby. 

A woolen shawl or wrap. 

1 Many obstetricians discard the use of all powders for a baby's skin. 



CHAPTER X. 

SIGNS OF THE APPROACHING LABOR THE PROCESS OF 

LABOR. 

Certain changes take place during the latter part of 
the ninth month which indicate that labor is approach- 
ing. One of these is the sinking of the abdominal en- 
largement. The upper part of the womb, which has at 
the beginning of the ninth month been high enough to 
reach the pit of the stomach, comes down gradually to a 
point about mid-way between the extremity of the 
breast bone and the navel. This sinking of the womb 
is known as " descent" or "settling" of the child, and 
indicates that the head of the child, which is ordinarily 
the part to be borne first, has stretched the lower part of 
the womb and is finding its way into the cavity of the 
pelvis, through which it must pass in the birth. Great 
relief to the mother results from this descent of the 
womb, as the lungs are no longer pressed upon to the 
same extent as before. The change in the position of 
the womb produces, however, an increased amount of 
pressure on the lower portions of the body. Swelling 
of the lower limbs is apt to result in consequence of this, 
and walking is rendered difficult. Piles, or hemorrhoids, 
are apt to form, and irritability of the bladder to exist. 

98 



SIGNS OF THE APPROACHING LABOR. 99 

During the last two weeks of pregnancy the patients 
are apt to suffer from what is known as " false pains" 
These are cramp-like pains, so much like labor pains 
that patients are often deceived by them, and led to 
imagine that the labor is really coming on. They are 
called "false pains" to distinguish them from the pains 
of labor, which are known as " true pains." The way to 
distinguish between the two kinds of pains is to observe 
whether there is any regularity as to the time of their 
occurrence; also, whether the interval grows shorter, 
and whether, with this shortening of the interval, the 
pains grow T stronger. " False pains" are irregular in 
their occurrence, while "true pains," though starting 
perhaps at quite long intervals, as three-quarters of an 
hour or a half -hour apart, gradually come nearer to- 
gether and grow stronger. "False pains," also, are 
generally located in the abdomen. "True pains" more 
frequently start in the back, coming forward to the 
abdomen and extending down the thighs. A strong 
"pain" is apt to be followed by one or two weaker 
pains. A nurse, if in doubt as to whether the pains are 
real labor pains or not, should have the physician sent 
for, who will make an examination to learn what the 
condition of the parts may be. A sign that makes it 
probable that the labor is really coming on is the ap- 
pearance of what is known as the "show" a discharge 
of mucus, tinged with blood, which comes from the 
mouth of the womb, and indicates that the stretching 
of the mouth of the womb is taking place. 



IOO OBSTETRIC NURSING, 

The whole process of labor is divided into three stages. 
The first is the stage of dilatation, when the mouth of the 
womb is stretching so as to allow the child to pass 
through it. With women who have never borne chil- 
dren this stage lasts on an average fifteen hours, while 
it is a very variable period for those who have previously 
borne children— sometimes lasting but three or four 
hours; the average time given is from seven to eleven 
hours. 

The second stage of labor begins after the completion 
of the stretching of the mouth of the womb and ends 
with the birth of the child. For women with their 
first birth, this period lasts from an hour to an 
hour and a half ; with others, from twenty minutes to 
an hour. 

The third stage of labor includes the interval between 
the expulsion of the child and the coming away of the 
afterbirth — on an average a half an hour or twenty 
minutes. 

The time for the entire labor, in a case where it is the 
first birth, is about seventeen hours. In cases where 
other children have previously been borne, the average 
is from eight to twelve hours. 

The "bag of waters 1 ' is a sac of membranes in which 
the child is enclosed. Within this bag is found a liquid 
in which the child floats. The presence of this liquid 
between the child and the w T alls of the womb serves to 
protect it from the effects of falls or blows to which the 
mother may be subjected, and favors the regular devel- 



SIGNS OF THE APPROACHING LABOR. IOI 

opment of the child. When labor begins with the 
stretching of the mouth of the womb, a small portion of 
this sac is pushed out like a wedge beyond the rim of 
the dilating orifice, and thus helps in the dilatation. 
When the waters break early, labor is much more tedious 
because the even pressure of the bag of waters on the 
mouth of the womb is lost, and the stretching cannot, 
therefore, go on so rapidly and easily. As the mouth 
of the womb opens, the poach formed by the bag of 
waters is pushed further and further out into the vagina, 
the pains become stronger, and the pouch at last bursts, 
letting the water escape. This is "the breaking of the 
waters," called by physicians the " rupture of the mem- 
branes," and it should not take place before the mouth 
of the womb is fully open. 

Labor, however, sometimes begins with this loss of 
water, as has been said in the chapter on the Accidents 
of Pregnancy. 

The pains of the first stage of labor are cutting, grind- 
ing pains, very hard for the patient to bear, and causing 
her to be nervous and irritable. 

The cries made by the patient during the first stage of 
labor are very different from those of the second stage. 
They are cries of complaint and suffering, while during 
the second stage they are rather groans accompanying 
a bearing-down effort on the part of the patient. The 
pains of the second stage are called " forcing" or " bear- 
ing-down pains." An experienced woman will know, 
as soon as these pains begin, that the doctor should be 



102 OBSTETRIC NURSING. 

on hand as soon as possible; and she should send him 
a message which will lead him to realize the necessity 
for coming at once. 

The pains during the second stage increase in strength 
and frequency ; the patient holds her breath and bears 
down forcibly with each pain. The effort causes her to 
become flushed and heated, and to break out into 
perspiration. 

During this time the head of the child is forced down 
the middle passage, or vagina, to the external opening. 
At the end of each pain the head goes back a little, so 
that the birth-track may be very gradually stretched. 
With women who have previously born children there is 
often so much relaxation of the tissues forming this pas- 
sage-way that the head of the child may be expelled by a 
single pain. This sudden birth of the head often causes 
very serious tears. 

After the external opening has been sufficiently 
stretched by the slow advance of the head, it gradually 
works out altogether, and then the worst pain is over. 
There is then a short interval of rest before the remain- 
der of the body is born, the shoulders coming first by a 
strong pain, after which the lower part of the body 
easily slips out. 

The contraction of the womb, or " pains," now ceases 
altogether from five to twenty minutes or even half an 
hour, when there is again a little pain and the afterbirth 
comes. 

The above description is an account of what labor 



SIGNS OF THE APPROACHING LABOR. IO3 

should be if perfectly natural. There are many emer- 
gencies which may arise in any case, hence, for the sake 
of the patient and nurse, every effort should be made, 
even in what promises to be a normal case, to have the 
doctor on hand in time. 



CHAPTER XL 

DUTIES OF THE NURSE DURING LABOR. 

With the occurrence of the symptoms which indicate 
the onset of labor the nurse, if not already in the house, 
should be immediately summoned. 

A nurse should give very prompt attention to such a 
call, and lose no time in getting to the patient, as many 
women pass through the different stages of labor very 
rapidly. 

On arriving at the patient's house, the nurse should 
put on her working clothes, which should always be 
scrupulously clean and of wash material. The uniform 
worn by the nurses of the Woman's Hospital of Philadel- 
hia consists of a blue and white striped seersucker 
dress, very plainly made; a large, plain white apron, 
with bib, well protecting the dress; over- sleeves, of same 
material as apron, for the protection of the dress-sleeves, 
and a white muslin Normandy cap. This makes a 
plain yet attractive dress — which is a matter of con- 
siderable importance to the patient, who gets her 
first impressions of her nurse through her personal 
appearance. 

Woolen dresses, or those made of any material which 
will not bear frequent washing, should never be worn by 
a nurse. There is always the possibility — in fact, the 

104 



DUTIES OF THE NURSE DURING LABOR. 105 

probability — of such a dress having been worn during 
her attendance upon some previous case of illness, in 
which case it would greatly endanger the patient. The 
feeling of the w T ash dress as it comes in contact with the 
patient's skin, when the nurse lifts her or works around 
her, is much more agreeable than that of woolen stuffs. 
Then, too, it is more business-like, looks more like work, 
and gives the patient the comfortable feeling that a nurse 
means to help her, rather than to sit around as a fine 
lady, attending simply to the daintier duties of attend- 
ance upon the sick. I introduce this subject here be- 
cause I find that many graduate nurses, in breaking 
their direct connection with their training schools, set 
aside as a matter of small moment this requirement con- 
cerning dress — a requirement in which a most important 
principle is embodied and which demands the hearty 
support of every truly scientific nurse. 

Another important point I wish to mention here, and 
that is that a nurse should learn to dress herself quickly, 
so that she can slip into the necessary garments in a 
very few minutes, and thus, by her promptness in re- 
porting for duty, awaken the confidence so essential to 
her management of patients. 

On entering the room where the patient is to be found, 
while exchanging the necessary greetings, the nurse 
should exercise her powers of observation and rapidly 
take in the state of affairs, forming her opinion as to how 
far the labor has progressed. Should " pains' ' be oc- 
curring, she will recognize from what has been said in a 



106 OBSTETRIC NURSING. 

preceding chapter of the pains characterizing the differ- 
ent stages of labor, whether the patient is really in labor 
or not, also how much time is probably left for the mak- 
ing of preparations. She can learn from the patient, in 
the intervals of her suffering, when the pains first 
began, how often they occur, whether the waters have 
broken, etc., so that she may know what message to send 
the doctor, should the necessity exist for so doing. 
After this duty has been performed, if labor has really 
begun, the nurse should give herself to the preparation of 
the patient and the room for the confinement. 

Preparation of the Patient. — The nurse should in- 
quire of the patient whether her bowels have been freely 
moved recently. If not, a simple enema of soap and 
water may be given for the purpose of clearing out the 
lower bowel and making the second stage of labor easier 
and cleaner. 

Inquiry should be made as to whether the patient has 
passed water freely. If not, she should be urged to make 
the attempt, and, if not successful, the physician should 
be notified. 

It is desirable, if there is time, to have the patient 
take a, full warm bath and put on entirely fresh clothing. 
The external genitalia should be washed off with a solu- 
tion of bichlorid of mercury 1-2000 or 1-4000 ; or some 
other antiseptic solution may be employed according to 
the choice of the physician. 

Preparation of Antiseptic Solutions. — Tablets of 
bichlorid of mercury may be obtained at any apothe- 



DUTIES OF THE NURSE DUEING LABOR. 107 

cary's, one of which, if added to a pint of water, will 
give, as a rule, a solution of i-iooo, from which solu- 
tions of varying strength may be made up by the addi- 
tion of more or less water. Thus, on adding seven parts 
of water to one part of the bichlorid solution i-iooo, 
a solution of 1-8000 may be obtained. It is always 
desirable that the nurse should have a little porcelain 
or agate-ware measure, by which she can readily and 
quickly prepare these solutions. If tablets cannot be 
obtained, powders of 71/2 grs. each of bichlorid of 
mercury, if added to a pint of water, will give a solution 
of i-iooo. 

Creolin, a coal-tar preparation, four times stronger in 
its antiseptic properties than carbolic acid or lysol, may 
be used in place of bichlorid of mercury. To make these 
solutions, 1/2 to 1 dram of the liquid preparation should 
be added to the pint of water. Creolin and lysol, though 
not so strongly antiseptic as bichlorid of mercury, have 
greatly come into favor of late, both because they do not 
have the same corroding effect on instruments which 
may be used, and because there is less liability of poi- 
soning than in the use of bichlorid of mercury. An 
objection has been raised to their use for vaginal injec- 
tions, as it is claimed that their admixture with blood 
produces a tarry precipitate. The coagulation of albu- 
min in vaginal discharges, by the action of corrosive sub- 
limate, is similarly claimed to deteriorate the value of 
the latter as an antiseptic agent. In cases where there 
is excessive discharge it may be better, therefore, to 



108 OBSTETRIC NURSING. 

substitute a solution of permanganate of potassium, or 
carbolic acid. 

A nurse should never lose sight of the fact that the 
corrosive sublimate (bichlorid of mercury) tablets are a 
deadly poison, hence there should be no neglect as to 
care in their handling. 

Carbolic acid solutions are preferably used by some 
physicians. A two per cent, solution of the latter may 
be made up by adding 21/2 drams to the pint of water. 

When the patient seems to be in active labor, the nurse 
should keep her lying down until after the physician has 
made an examination. He will then state whether the 
patient may sit up or walk about the room. 

Because of her long confinement to bed the hair of 
the patient should be arranged so that it will be most 
comfortable and not readily tangled. The best arrange- 
ment is that of parting the hair down the back of the 
head and braiding it into two plaits — one behind each 
ear. This leaves a smooth surface at the back of the 
head to lie upon. 

The outfit of the patient during the labor should con- 
sist of a merino vest, long night-dress, a pair of large, 
roomy, open drawers, and a pair of stockings. While 
walking about the room, and until the second stage of 
labor begins, she may wear a wrapper over the rest of 
her clothing and have on a pair of bedroom slippers, 
which can be easily slipped off when she needs to lie 
down. 

The patient should be told by the nurse of the neces- 



DUTIES OF THE NURSE DURING LABOR. 109 

sity for an examination by the physician, particularly if 
this is her first labor. When the physician comes, the 
patient should be placed on the bed, near its edge, lying 
on her back or side, as he may prefer, with her limbs 
drawn up toward the abdomen. Her clothing should 
be lifted above the hips, and a sheet, or some light cover- 
ing, used to protect the lower part of the body from ex- 
posure. Cleanse the vulva with green soap mixture and 
water, followed by bichlorid mixture 1-10,000 and 
sterile water. A chair should be placed for the physi- 
cian on the same side of the bed, close to its edge, facing 
the patient as she lies; a jar of sterile vaselin should 
be brought him, and all the necessary materials pro- 
vided for the proper cleansing of his hands both before 
and after the examination; soap, nail-brush, warm 
water and towels, and some disinfectant solution, as a 
bichlorid of mercury solution of the strength 1-2000, 
or creolin, a dram to a pint of water, or lysol in 
the same proportion. Also a pair of sterile rubber 
gloves. 

The preparation of the room and bed will next 
require the nurse's attention. 

These preparations should be made as quietly as pos- 
sible. The nurse should have learned beforehand where 
things are, and she should have had them so arranged 
that but little will need to be done at the time, except to 
put them where they will be most convenient for use . 
It is well, if the patient is walking about, to have her go 
into the next room while the bed is made up. 



IIO OBSTETRIC NURSING. 

A single bed is always the most convenient in the man- 
agement of a patient, but such are rarely found in pri- 
vate houses. The preparation of a single bed would 
be as follows: First, the mattress — preferably of hair 
—covered by a pad and rubber-protective across the 
middle of the bed, or covering the bed entire. (Rubber 
army-blankets are used in the Woman's Hospital for 
this purpose.) The under sheet covers this rubber, and 
a draw-sheet — a sheet folded four times in its length 
and placed across the portion of the bed upon which 
the hips would rest — comes next. (The folded side of 
the draw-sheet should be toward the head of the bed.) 
This constitutes the first dressing, or what is known as 
the " permanent bed." The different articles constitut- 
ing this dressing are securely fastened down by safety- 
pins. Over the "permanent bed" comes the "tem- 
porary bed" consisting of a second gum blanket, cover- 
ing the entire bed, a second under-sheet and draw- 
sheet. Covering these are the upper sheet, blanket, 
and spread. 

After the confinement, the " temporary bed" can be 
drawn from under the patient, leaving her lying on the 
" permanent bed." The change is accomplished with 
much greater ease for both patient and nurse than the 
changing of the various articles separately. 

The double bed found in most private houses is ar- 
ranged as follows: First, the ordinary dressing of the 
bed, the hair-mattress, pad, rubber-protective, under- 
sheet, and draw-sheet. Upon top of this dressing, at the 



DUTIES OF THE NURSE DURING LABOR. Ill 

lower right-hand corner of the bed, a "temporary dress- 
ing* ' should be arranged, about a yard and a half square, 
consisting of a rubber protective, or the paper pad before 
described, securely fastened down to the bed beneath, 
and covered, if rubber, simply by a folded sheet, like- 
wise fastened down by safety-pins. If the paper pad 
is used, an old comfortable or blanket will be needed 
beneath the sheet. The pillow for the patient should 
be placed at the upper and inner corner of this square. 
After the delivery, she can be lifted to the upper part 
of the bed, and the "temporary dressing" removed. 

The sheet, blanket, and spread which are to serve as 
her covering after the delivery may be kept from soiling 
during the labor if folded upon themselves several times 
and carried to the extreme edge of the left side of the 
bed. Another sheet and blanket may be used as tem- 
porary covering during the delivery. It is so important 
that a patient shall be moved as little as possible imme- 
diately after the labor, because ctf the tendency to bleed- 
ing produced by motion, that the nurse should study 
carefully the best methods of protecting patient and 
bed from soiling, so that it will be necessary to do but 
little in the way of changing the clothing. 

The piece of floor oil-cloth must be spread at the side 
of the bed, extending from a foot to a foot and a half 
under the bed. 

There should be a bureau with a set of drawers, or a 
closet, with shelves, in the room, given up to the nurse 
for the keeping of the various articles she may need, and 



112 OBSTETRIC NURSING. 

these articles should be conveniently arranged so that 
there may be no confusion in obtaining them when re- 
quired at any time. One drawer or shelf should con- 
tain sheets; another towels and napkins and soft, clean 
muslin or linen rags, to be used as napkins during the 
delivery; a third should contain changes of underwear 
for the patient, and a fourth the baby's wardrobe. 

A change of clothing for the mother should be placed 
— if it is warm weather— in the sun by a window ; if in 
winter, by the register or stove, so as to be dry and 
warm should it be needed. 

The baby's suit should in the same way be aired and 
warmed. The baby's basket should be placed on a chair 
or stand near the register, with all the necessary articles 
for its toilet and bath — a baby's bath-tub or an ordinary 
foot-tub, soft towels, nurse's flannel bathing-apron, a 
little sterilized cosmolin in a jar, etc. Two pieces of 
bobbin, each eight inches in length, should be put in a 
little vessel containing some bichlorid solution, 1-4000. 
These, with a pair of blunt scissors, should be placed 
where they can be conveniently reached for the tying 
of the cord. Some small squares of soft muslin or 
linen should be placed where they will be convenient 
for the immediate cleansing of the child's eyes after 
expulsion of the head. A flannel blanket or good warm 
flannel petticoat should be provided for receiving the 
child upon its birth. The baby's crib should also be 
prepared for its reception. 

Beneath the bed there should be two chambers — one 



DUTIES OF THE NURSE DURING LABOR. 113 

for urine and one for the after birth, or a tin basin may 
be provided for the latter. 

A vessel for the patient to vomit in should be on hand 
— a chamber, or even a chamber-lid, will do very well. 

A basin filled with warm solution ofbichlorid of mercury, 
1-4000 or 1-2000, should stand near the bed, or, if 
preferred, the creolin or lysol solution, so that the nurse 
or physician may repeatedly cleanse the external organs 
of generation of all discharges during the progress of the 
labor. The solution in this basin should be frequently 
changed. 

A sufficient number of soft linen or muslin rags will 
also be necessary for this purpose. 

Agate, porcelain, or china basins are necessary when 
bichlorid solutions are used. For creolin or lysol ordi- 
nary tin basins will do. 

The nurse should never allow anything from the 
kitchen to be pressed into service for such an occasion. 
The indiscrimiate use of pans, basins, cups, and saucers 
is certainly vulgar, to say the .least. The ' 'eternal fitness 
of things' ' should never be lost sight of. 

A urinal, or a soap-cup, which is a good substitute; a 
glass catheter, and an English rubber catheter, No. 8 or No. 
9 ; a bed-pan, and the other receptacles for the various 
purposes above referred to, may be placed for con- 
venience beneath the bed. 

A towel-rack near by should contain at least half a 
dozen fresh towels. 

A few napkins, a supply of soft rags, a waste-bucket or 
8 



114 OBSTETRIC NURSING. 

slop-jar, with a lid, should be found in the room; and an 
abundant supply of hot and cold water. 

As soon as the patient is known to be in labor, the 
nurse should go to the kitchen to see that the fire is good 
and that plenty of water is put on to boil. An arrange- 
ment should also be made by which some member of the 
family will be prepared to respond to the nurse's call for 
more hot water when it is required. The abdominal 
bandages for the patient, with the towel containing the 
sterilized dressings and a pin-cushion containing safety- 
pins, should be placed on the stand beside the bed. 

A bottle of whisky or brandy, and one of hartshorn 
should be provided. 

A pitcher of cool water and a tumbler should be found 
in the room, as the patient may need a refreshing drink 
during the progress of the labor. A feeder is best pro- 
vided for the patient's use, as she can then drink lying 
down. 

The arrangement of the patient's clothes to keep them 
from soiling during the expulsive stage of labor will 
require some care on the part of the nurse. The night- 
dress or vest should be folded or rolled up beneath the 
arm-pits and fastened with safety-pins over the right 
side of the chest. If the patient wears large drawers, no 
further protection than the cover-sheet may be neces- 
sary. Some prefer having a sheet adjusted around the 
waist, above the abdomen, and pinned under the cloth- 
ing to the right side, the long end of the sheet which 
remains, and which should be the anterior part, is 



DUTIES OF THE NURSE DURING LABOR. 115 

plaited up and fastened also beneath the right arm by 
means of safety-pins. The sheet thus resembles a skirt 
opened at the right side. 

During the Early Stage of Labor the nurse will need to 
encourage the patient, and by a sensible, quiet, yet 
cheerful bearing keep her strong. It is of no use for 
patients to hold their breath and bear down during each 
pain in this stage, and nurses should never urge their 
patients to do so. It should be left to the physician to 
decide when bearing-down efforts are desirable. The 
pressure of the nurse's hand upon the back during a pain 
often gives great relief to the patient, while the occa- 
sional bathing of the face and hands with cold water is 
refreshing. Frequent sips of cold water may be per- 
mitted. 

Nourishment in form of beef-tea, gruel, milk, and tea 
may be given from time to time if the labor be long. 
No stimulants should be given without the direction of 
the physician. 

Vomiting is a troublesome though not necessarily a 
dangerous symptom during delivery. In fact, the re- 
laxation it produces is often desirable. If it is excessive, 
however, a little iced soda water may check it. 

Cramps in the lower limbs are a very frequent accom- 
paniment of the second stage of labor. Relief may be 
obtained by stretching the limb straight out, gently rub- 
bing the painful muscles, or grasping and holding them. 

Friends and Neighbors should, if possible, be expelled 
from a confinement room. Their injudicious tales and 



Il6 OBSTETRIC NURSING. 

expressions of sympathy are often absolutely painful. 
The nurse has to manage this with great tact. She can 
generally succeed best by stating to the friends that it 
is the physician's wish she should do so, and her relations 
toward the physician require that she should implicitly 
observe his directions. If the nurse does not allow her- 
self to become familiar with her patients, but maintains 
a quiet dignity in the carrying out of her directions, her 
requests will generally be observed. 

Tact is a magic wand by which human beings can 
accomplish miracles in the way of subduing the obsti- 
nate. Happy is the nurse who possesses it! The best 
rule for acquiring it is the Golden Rule, "Do unto 
others as you would that they should do to you." A 
strict observance of this will insure a kindness of tone 
and manner in the making of requests which will win 
consent when it would not otherwise be granted. 

Duties of Nurse. — One of the most important duties 
of the nurse during the confinement is the frequent 
changing of napkins, draw-sheets, towels, etc., used 
about the patient. Also the frequent renew y al of the 
antiseptic solutions to be used for her, or for the doctor's 
hands. 

Antisepsis means, literally, " against poisoning," and 
implies the careful removal of all sources of poisoning, 
such as would come from decomposing blood and dis- 
charges or dirty articles. The physician's and nurse's 
hands, therefore, require a special preparation for the 
labor in their thorough disinfection. During the course 



DUTIES OF THE NURSE DURING LABOR. 117 

of the labor the hands should be thoroughly cleansed 
with a bichlorid solution whenever they have touched 
anything unclean, or whenever they come in contact 
with the genital organs. 

Position for Delivery. — The patient may be deliv- 
ered on her back or lying on her left side. When the 
physician desires the change of position, the nurse must 
help the patient to turn on her side and bring her hips 
close down to the edge of the bed. The upper or right 
limb will then have to be supported by the nurse, in 
order to well separate the thighs until the delivery is 
effected. (When there is insufficient help, a pillow may 
be used between the knees.) She will have to get on 
the bed close to the patient for this, and hold the leg at 
knee and ankle. After the child has come, she should 
help to turn the patient in the bed, bring a flannel wrap 
to put the baby in as it lies on the bed before the tying 
of the cord, and throw a covering over the mother's 
chest. She should then wipe the baby's eyes with a fine, 
soft piece of linen dipped in tepid water, or a saturated 
solution of boric acid ; should bring the doctor the scis- 
sors and bobbin, and have ready a sheet for receiving 
the child and a vessel for the afterbirth. She should 
hold the sheet doubled upon her outstretched arms, the 
side toward her being held up by her chin. On receiv- 
ing the baby with its flannel covering, she allows the 
edge of the sheet held up by her chin to drop down over 
the child. She then folds over the hanging ends, so as 
thoroughly to cover the child, and places the little bun- 



Il8 OBSTETRIC NURSING. 

die in a crib to await further attentions, until the mother 
has been made comfortable. Should the child breathe 
imperfectly, the physician will give it his own attention 
or direct the nurse what to do. 

Disposal of Afterbirth. — The vessel containing the 
afterbirth, if the latter has been detached from the child, 
may be placed temporarily under the bed, to await the 
physician's examination. If the cord has not yet been 
tied, the vessel may be put in the crib with the baby. 
Many physicians do not tie the cord or navel-string until 
there is no further pulsation in the vessels. 

Attentions after Labor. — Should the physician not 
desire to do so, the nurse should next attend to the 
cleansing of the mother's external parts by means of soft 
cloths dipped in a solution of bichlorid of mercury 
1-4000, or whatever solution the doctor may direct. 

Many physicians make a practice of using a vaginal 
injection of some disinfectant solution immediately 
after delivery. It will be the nurse's duty to prepare 
this should it be called for. The " temporary dressing" 
should be removed from the patient, and she should be 
gently lifted on to the upper portion of the bed. The 
binder and dressings must next be applied. 

The binder must be rolled up to half its length, and 
the rolled portion passed beneath the patient's back. 
It is then caught on the other side and unrolled, straight- 
ened so as to be free from wrinkles, and made to encircle 
the hips tightly. The overlapping ends are then 
fastened together by means of safety-pins down the 



DUTIES OF THE NURSE DURING LABOR. 119 

front. The middle portion of the bandage should be 
tightened first, as the firmest pressure should be directly 
over the upper portion of the womb. The lower portion 
of the bandage is fastened next, and the pins in the upper 
portion placed last, as this does not need to be so firmly 
applied. 

The antiseptic dressings should next be applied in the 
order described in the preceding chapter. The napkin 
is spread out and fastened to the abdominal bandage 
anteriorly, so as to fit over the convexity of the upper 
portion of the external organs of generation and extend 
from groin to groin. Posteriorly it is fastened to the 
abdominal bandage by but one safety-pin. This makes 
an "occlusion dressing." 

The patient's body-clothing should then be unfastened 
and drawn down (her drawers and stockings should 
have been removed with the " temporary dressing"). 
The coverings of the bed are drawn up over her, and she 
is allowed to lie quietly until the nurse cleans up the 
room and makes preparations for washing the baby. 

The physician generally remains with the patient an 
hour after the delivery, taking her temperature and 
pulse, and watching the condition of the womb, to 
insure against danger of hemorrhage from want of 
proper contractions. 

After the doctor leaves, this duty devolves upon the 
nurse, who should examine the dressings frequently to 
see that the bleeding is not too profuse, and place her 
hand over the lower part of the abdomen to feel the 



120 OBSTETRIC NURSING. 

womb, which, if properly contracted, should be a round, 
hard body about the size of a child's head, immediately 
above the pubic bone, and not reaching higher than the 
navel. The consideration of the accidents of labor and 
the care of the infant will be treated in other chapters. 



CHAPTER XII. 

ACCIDENTS AND EMERGENCIES OF LABOR. 

Women who have borne children before are apt to 
have rapid labors, hence a nuise should be on her guard 
when in attendance upon such a patient, watching for 
the symptoms of approaching labor, and notifying the 
physician earlier than she would feel warranted in doing 
with a patient expecting her first confinement. As soon 
as the nurse suspects that labor pains have begun, she 
should put her patient to bed. When " bearing-down" 
pains begin, the patient should not get up even to use 
the chamber. A bed-pan should be used. The patient 
should not be allowed, when the pains come on, to 
catch hold of anything to increase the force of her effort. 
Above all, the nurse should not tell her to bear down. 

The strength of the pains is somewhat modified if the 
patient is kept on her side. This position is also safer for 
the perineum, which does not so directly get the full 
force of a pain as when the patient lies on her back. 
The left side is preferable, as it enables the nurse to use 
her right hand to greater advantage. 

Should the child's head come down so that it can be 
seen at the entrance to the vagina, the nurse should place 
herself on the right side of the bed, and as the patient 
lies on her left side, with the hips well drawn to the edge 

121 



122 OBSTETRIC NURSING. 

of the bed, the nurse should gently hold back the baby's 
head during a pain. This is to prevent a tear from oc- 
curring by the sudden expulsion of the head. She 
should favor the gradual stretching of the parts. She 
should avoid interfering in any way, as in making efforts 
to enlarge the opening by stretching it with the fingers, 
etc. All such attempts will inevitably result in harm. 
When the opening is sufficiently stretched, the head will 
slip out of itself. 1 The passage of the child's head is 
rendered easier if the patient's knees are separated by 
a pillow. The nurse should simply continue to support 
the head with her hand, and as soon as the head is born 
her left hand should be placed over the mother's abdo- 
men, resting upon the womb, which may be distinctly 
felt through the abdominal walls. The pressure of the 
hand acts as a stimulant to the womb, and induces 
good contractions. A tendency to hemorrhage is thus 
averted. The right hand of the nurse should support the 
child's head. With one finger she should feel around 
the baby's neck to learn whether it is encircled by 
a loop of the navel-string or cord. If so, she should 
gently pull first on one side and then on the other, of the cord, 
to see which end is loose. This relieves the pressure 
and prevents the stoppage of the circulation in both 
cord and child's neck. 

1 When the approach of the expulsion of the head is indicated by the increas- 
ing thinness of the perineum, the perineum may be supported by placing the 
palm of the other hand over the posterior portion of the perineum and 
pressing it forward toward the pubes. This relieves the edge of the perineum 
from strain. 



ACCIDENTS AND EMERGENCIES OF LABOR. 1 23 

When, after a pause, the pains start up again to 
expel the rest of the child's body, the nurse had better 
have some one instructed how to hold the womb prop- 
erly, as both her own hands will be needed to receive 
the body of the child as it is expelled. The mother her- 
self may be shown how T to make this pressure over the 
womb. If there is no one to make this compression of 
the womb, the nurse should try to manage the baby 
with one hand and keep up the pressure over the lower 
part of the abdomen with the other. The flannel 
wrap for the baby may be put close up to the mother's 
hips, and the nurse can manage with one hand to lay 
the baby down on this, cover it up, and draw it far 
enough away from the mother's hips to keep it out of 
the discharges. She should see that the baby's mouth 
is free from liquids. The little finger of her right hand act- 
ing as a hook, the end of the finger should be passed in at 
one corner of the baby's mouth and out of the other 
corner, thus scooping out any liquids that may have 
been drawn in during the birth. She should be careful 
to see that the cord is not dragged upon and that the 
baby breathes well. Babies usually cry lustily just after 
the birth. This should be a welcome sound to both 
nurse and mother, as it ensures expansion of the lungs. 
Occasionally, a child will be born with what is known as 
a "veil" or "caul" — a portion of the membranes drawn 
tightly over the face. This may cause death from 
suffocation unless it is quickly seized by the fingers and 
torn off, so as to free the child's mouth and nose. 



124 



OBSTETRIC NURSING. 





i 



Fig. 30. — Suspension 
of the Asphyxiated 
Newly Born Child by 
the Feet to Assist 
Gravity in Freeing the 

AIR-PASSAGES OF FOREIGN 

Matter. {Edgar.) 



Resuscitation of Baby. — If the 

baby is apparently lifeless when 
born, besides the measures spoken 
of for clearing its mouth of liquids, 
it may be turned over on its face, 
to empty out the discharges from 
the air-passages, and efforts should 
be made to start breathing. The 
head of the child should be lowered, 
to keep as much blood there as 
possible. Hold the child up by 
the ankles with its head down to 
facilitate the escape of liquids from 
the air passages and rub the child's 
back briskly up and down the 
spine with a coarse towel. 

The back may be slapped — 
several short, quick slaps given 
over the buttocks. A stream of 
cold water may be poured on the 
chest just for a moment, and this 
repeated several times. 

If these measures fail, the nurse 
may breathe into the baby's mouth. 
To do this properly, the baby's 
nose should he held, the nurse's 
lips placed closely over the baby's 
open mouth, as she breathes into 
it, then the nurse's mouth is re- 



ACCIDENTS AND EMERGENCIES OF LABOR. 



125 



moved and the grasp on the nose loosened, the sides 
of the child's chest being pressed upon to press out 
the air. The number of breaths 
given by the nurse in a minute 
should not at first exceed twelve. 
Byrd-Dew Method. — A most 
valuable method of carrying on ar- 
tificial respiration, recently revived, 
is that known as the Byrd-Dew 
method, the different movements 
of which are well shown by the ac- 
companying illustration. The op- 
erator holds the neck of the child 
between the thumb and the index 
finger of one hand, while the other 
hand holds the child at the nates. 
The first step (Fig. 32) is to flex the 
body of the infant along its dorsal 
surface as much as possible, bending 
the spine well backward ; then grad- 
ually to flex it upon its ventral sur- 
face, bringing the head in close ap- 




Fig. 31.- 



-suspension 
of the Asphyxiated 
Newly Born Child by 
the Feet, and Clean- 
ing the Posterior 
Pharynx op Foreign 
position to the lower extremities Matter With the Lit- 
/t^* j * \ t ■ i.t- r a tle Finger Wrapped 

(Figs. 33 and 34). In the first move- WITH Gauze {EdgaTm) 
ment the diaphragm is pulled down 
mechanically, as a result of the descent of the abdominal 
organs. We thus imitate inspiration, and during the 
manipulation may often hear air entering the trachea. 
As the body of the child is bent forward, the diaphragm 



126 



OBSTETRIC NURSING. 




Fig. 32. — -Byrd's Method or Artificial Respiration. Position for 

Inspiration. (Edgar). 




Fig. 33.— Byrd's Method of Artificial Respiration. Position Be- 
tween Inspiration and Expipation. {Edgar). 



ACCIDENTS AND EMERGENCIES OF LABOR. 1 27 

is pressed upward and the walls of the chest are com- 
pressed. Thus the expiratory act is accomplished ; and, 
during it, not only air is driven out, but the mucus and 
amniotic liquid that may have entered the air-passages. 
These movements may be carried on while the sur- 
face of the child is kept beneath hot water the greater 




V 3L 






Fig. 34. — Byrd's Method or Artificial Respiration. Position for 

Expiration. {Edgar). 
Note the inversion of the child to assist in freeing the air-passages. 

part of the time — which is a decided advantage over 
some of the other methods of resuscitation, especially 
in asphyxia of the second degree, when the surface of 
the child is very pale, showing it to be suffering greatly 
from shock. It is always important in such cases to 
keep the body of the child warm. The movements 
should not be too rapidly performed — about three times 
to the minute is often enough. 

Alternating with artificial respiration, warm baths 



128 



OBSTETRIC NURSING. 



may be employed from time to time. The temperature 
of the bath should be ioo° Fahr. Ground mustard may 
be put in the water. After- breathing is established, the 




Fig. 35. Fig. 36. 

Prochownick's Method of Resuscitation. 



child should be placed in warm wraps, with bottles of 
hot water around it. 

Method of Prochownick, of Hamburg. — A method 
of resuscitation that has been employed with great sue- 



ACCIDENTS AND EMERGENCIES OF LABOR. 1 29 

cess for many years by Prochownick, of Hamburg, in 
the severer grades of fetal asphyxia, is carried out as 
follows: As soon as delivered, the child is seized by its 
feet, as shown in Fig. 35 ; the child's forehead is allowed 
to rest lightly on a table or some other surface, the face 
being extended, so that the chin is thrown well forward 
and the trachea, or windpipe, freed from all compres- 
sion. The mouth in this position hangs open. While 
an assistant holds the child in this position, the oper- 
ator grasps the chest with both hands (see Fig. 35), 
and makes compression over it, thus imitating the act 
of expiration, by which discharges drawn into the air- 
passages may be expelled. A relaxation of this com- 
pression permits expansion of the chest, and thus inspi- 
ration is effected. These movements are carried on 
rhythmically until natural breathing is established. 
When an assistant can not be had, the manoeuvre can 
be carried on as shown in Fig. 36, by means of one hand, 
although less efficiently. 

Laborde's Method. — Still another new method of re- 
suscitating an infant has been employed of late in 
France. The tip of the tongue being seized by means of 
a towel and held between the fingers, or by means of the 
ordinary tongue forceps, the organ is drawn well forward 
and then pushed backward. Rhythmical movements 
of the tongue are thus kept up until respiration is 
established. * 

1 The Marshall Hall and Sylvester methods of resuscitation are more 
efficacious when employed for adults than in the case of infants, hence have 
not been considered in this connection. 



130 OBSTETRIC NURSING. 

Relapses after resuscitation are very common — hence 
a child will need to be watched very closely after such 
measures have been employed, until sufficient time has 
elapsed to fully persuade both doctor and nurse that the 
action of the respiratory apparatus is normal. For at 
least twenty-four to forty-eight hours a resuscitated 
child should have a special attendant, whose business it 
will be to watch it. If not doing well such care may be 
needed for a longer period. 

Tying of the Cord. — If all is well with the child, it is 
best not to tie the cord until all pulsation ceases in it. 
This measure is thought to save the child some loss of 
blood. As the pulsation may last for an hour or more 
after the delivery, the afterbirth is generally expelled 
before the cord is tied. To tie the cord, two pieces of 
bobbin, each eight inches long, dipped in a bichlorid 
solution (1-4000) or in some other antiseptic solution, 
or dry sterilized, should be used. The first ligature 
should be placed two finger breadths from the child's 
abdomen. The string should be carried underneath the 
cord. In making the first tie, two twists instead of one 
should be taken to keep it from slipping. If the thumbs 
are placed upon the string in tying, the ligature can be 
drawn more tightly, and the grasp of the ends of the 
bobbin is more secure. The second knot is tied the 
same way. The ends may then be looped, making a 
bow-knot. The cord should be stripped, that is, the 
blood remaining in the vessels squeezed out toward the 
afterbirth, before each ligature is thrown around it 



ACCIDENTS AND EMERGENCIES OF LABOR. 131 

The second ligature is one inch further away from the 
insertion of the cord into the child's abdomen. After 
this second ligature is tightened, hold the cord with the 
forefinger and middle finger at the ligature nearest the 
child, the thumb and other fingers at the other ligature, 
and cut it with a pair of dull scissors between these points. 
The extremities of the scissors are thus made to look 
toward the palm of the hand, and a sudden movement 
on the part of the child does not result in the same danger 
to it as there would be were the points not thus protected. 
After the cord is cut, squeeze the remaining blood out 
from the end next the child. The scissors for this pur- 
pose are preferably dull, as the more ragged wound thus 
produced favors the closure of the blood-vessels. This 
lesson may be learned from nature, the lower animals 
gnawing off the cord after giving birth to their young, 
and thus no doubt decreasing the danger of bleeding. 
As soon as the cord is cut, a sterile dressing should be 
applied consisting of a small gauze sponge with a hole 
cut in its center through which the cord is slipped, and a 
sterile binder made of a strip of gauze eighteen inches 
long by eight inches wide, folded in four lengthwise, 
this is wrapped around the abdomen snugly covering 
the cord and the gauze sponge. 

Position for Delivery of Afterbirth. — The best position 
for the mother during the delivery of the afterbirth is on 
her back, hence she may be turned after the nurse has 
satisfied herself that the baby is in good condition. 

Twins. — Very occasionally, on placing her hand over 



132 OBSTETRIC NURSING. 

the abdomen, after the delivery of the child, the nurse 
may feel another child there. In this case she must 
simply keep the womb well contracted by rubbing it 
gently through the abdominal walls, and wait for nature 
to go on with the work of expulsion. This baby must 
be cared for as the other. 

The afterbirth generally comes away within twenty 
minutes after the child's birth. Two or three pains 
occur, during which the nurse should keep the womb 
in the middle line of the abdomen and make gentle 
pressure backward and downward. With her right 
hand she should seize the afterbirth and membranes 
and twist them around several times to make a cord of 
the membranes, so that they may not tear, but all be 
expelled at once. A discharge of blood and some clots 
generally follows the delivery of the afterbirth. The 
nurse's left hand should still be kept carefully over the 
womb, which should feel hard and firm and should not 
reach above the navel. If it does not feel firm, rubbing 
over the lower part of the abdomen should again be re- 
sorted to until the round, hard body is felt. 

If the afterbirth does not come^for an hour, and the 
physician has not yet come, advise sending for another 
doctor. * 

After the afterbirth has come, it should be put in a 

1 Sometimes the placenta or afterbirth, is adherent and will require to be 
separated from the uterine wall by the finger. If it is simply retained by 
what is called hour-glass contraction of the uterus, the expulsion will occur 
with the relaxation of the contraction, though an anesthetic may be necessary. 
Gentle pressure over the uterus is all that is necessary. 



ACCIDENTS AND EMERGENCIES OF LABOR. 133 

clean vessel, and, if detached from the baby, put in an 
adjoining room for the doctor to examine when he 
comes. Insist upon his seeing it, to find out whether 
it is all there. Have the baby removed to its crib and 
placed on its right side and properly covered. 

After-care. — Watch the womb carefully until the 
doctor comes. If it be firmly contracted, and no more 
blood be flowing from the vagina, place some dry nap- 
kins or a clean sheet under the patient, and wash off 
the thighs and surrounding parts with warm water con- 
taining bichlorid in the strength of 1-4000, and dry 
with a soft cloth. 

Slip the soiled clothing from under the patient, and 
then apply the binder and dressings, and make her 
comfortable. 

As soon as the doctor comes, report to him the exact 
time when the waters broke, when the baby was born, 
and when the afterbirth came. It is always best for a 
nurse to keep a written report with a statement of what 
she did. She should not, however, neglect her patient 
for the purpose of perfecting her report. 

Breech Delivery. — Sometimes a nurse has the misfor- 
tune to be the only attendant at a breech delivery ; that is, 
instead of the child's head coming first the breech 
passes out from the birth-canal. Delivery in this man- 
ner is very dangerous to the life of the child. The nurse 
should do absolutely nothing here, as she would only 
make matters worse in trying to assist. These de- 
liveries are long enough, as a rule, to give ample time for 



1 34 



OBSTETRIC NURSING. 



the summoning of some doctor to take charge of the 
case. In all breech cases the child is apt to need to be 
resuscitated, if it is alive at all; hence plenty of warm 
water, etc., should be ready for the bath. 

Hemorrhage. — Flooding from the womb, or "uterine 
hemorrhage/' is apt to occcur either within the first 
twenty-four to forty-eight hours after the birth, when 




Fig. 37. — Position of Patient in Hemorrhage after Labor. 



it is called "primary hemorrhage;" or it may occur 
some days after, when it is "secondary hemorrhage." 
The appearance of blood, either a constant oozing or a 
sudden gush from the vagina, is, of course, the earliest 
symptom. 

A pulse of over 100 in a patient freshly confined 
should make the nurse exceedingly watchful in this re- 
spect, as it betokens a liability to hemorrhage. Should 



ACCIDENTS AND EMERGENCIES OF LABOR. 1 35 

the flow continue, the patient becomes pale, faint, rest- 
less, gasps for breath, and finally dies unless the hemor- 
rhage is checked. A nurse should, of course, have the 
physician sent for at once, although he may have just 
left the house, or another doctor should be summoned. 
In the meantime, her first thought should be of the 
uterus and its probable condition of relaxation. The 
bandage, if applied, should be hastily removed, and 
the hand placed over the lower part of the abdomen. If 
the womb is not felt, rub vigorously until it contracts 
and is felt again as a round, hard body. Keep on rub- 
bing and holding. The nurse should never take her 
hand off the abdomen until the doctor comes. Direct 
some one else to take the pillows from under the patient's 
head, have the foot of the bed elevated, to keep the 
blood in the head and prevent fainting, which induces 
heart-clot. Have the foot of the bed placed on the 
seats of chairs. The patient may be fanned, cold 
water given her to drink, hartshorn to smell. She 
should not be allowed even to turn in bed or lift her 
head. If the doctor has left ergot, one teaspoonful of 
the fluid extract may be given in a tablespoonful of 
water. The patient should receive this without lifting 
her head. Plenty of hot water should be on hand, the 
water in the tea-kettle boiling. If the physician delays 
his coming and the flow continues, repeated hot-water 
injections of about ii5°-i2o° should be given into the 
vagina. 

Convulsions may come on during the labor as during 



136 OBSTETRIC NURSING. 

the pregnancy. Their management would be the same 
as that suggested for convulsions during pregnancy. 

Other accidents, such as rupture of the uterus, or the 
coming down of an arm or hand, or the navel-string in 
advance of the usual part to come first, are conditions 
in which the nurse can do nothing, except to keep the 
patient as quiet as she can, and meddle as little as pos- 
sible until the doctor comes, for whom, of course, she 
must at once send. 1 

Deportment. — At no time, in the management of a 
case, should a nurse express surprise or consternation, 
nor should her manner indicate that she has such feelings. 
Like a true soldier, she must bravely and quietly face 
the most critical situations and meet their demands. 
She should by her manner give the mother to feel that 
all life's vicissitudes are best met by a quiet self-control. 

Fortunately, deaths during delivery in this enlight- 
ened age are few ; for the methods of averting accidents 
at such times have been so thoroughly studied that 
accidents themselves are very rare. 

1 In prolapse of the cord, or navel string, it is often an advantage to keep the 
patient in the knee-chest position until she can be seen by a physician. This 
removes pressure from the cord. 



CHAPTER XIII. 

OBSTETRIC OPERATIONS. 

The preparation of the patient is identical for all 
minor obstetrical operations and is as follows: The 
patient lies across the bed or on an operating table in 
the lithotomy position with her hips resting upon a 
Kelly pad, her legs supported by stirrups, a leg-holder, or 
a "twisted sheet. The lower abdomen, vulva, perineum 
and inner surface of the thighs is cleansed with green- 
soap mixture and sterile water, followed by bichlorid 
1-10,000 and finally by sterile water. The vulvar hairs 
are clipped or shaved and a pair of sterile leglettes is 
slipped on. 

Anesthesia may or may not be used, depending upon 
the extent of the operation, the sensitiveness of the 
patient, and the presence of adequate assistance. 

Instruments are prepared by boiling in soda for five 
minutes; needles, scissors and knives, by boiling for 
two minutes, after which they are kept in alcohol. 
Tubes of catgut are boiled for one minute and silkworm 
gut is boiled for five minutes in plain water. 

Provide for the operator and assistants basins of 
hot water, soap, nail-brushes, nail file, a basin of bi- 
chlorid solution 1-2000 and one of sterile water, sterile 
gowns, caps and gloves. Provide plenty of sterile 
gauze sponges. Place a chair for the operator, a 

137 



I38 OBSTETRIC NURSING. 

table for instruments and sponges, and a basin of sterile 
water for rinsing the hands. 

Perineorrhaphy, or repair of the perineum. — This 
operation may be performed immediately after delivery 
or upon the fifth day. The following instruments are 
required : 

Three double tenacula. 

One dozen hemostats. 

Tissue forceps. 

Needle holders. 

Needles. 

Scissors. 

Also suture material of silkworm-gut or cat- 
gut (plain No. 1, chromicized Nos. 1 and 2). 
Trachelorrhaphy, or repair of the cervix, may also be 
performed immediately after delivery or on the fifth 
day. The instruments required are : . 

Weight or Sims speculum. 

Right-angled vaginal retractors. 

Two volsellum forceps. 

Six hemostats. 

Long tissue forceps. 

Needle-holder. 

Needles. 

Suture material of catgut (chromicized No. 2). 

Artificial Dilatation of the Uterus by the Insertion 

of Dilating Bags. — Artificial dilatation may be resorted 

to in the induction of premature labor or in placenta 

praevia where the bag also serves to arrest hemorrhage. 



OBSTETRIC OPERATIONS. 1 39 

Instruments required : 

Weight or Sims speculum. 
Right-angled vaginal retractors. 
Volsellum forceps. 

Long-curved forceps for grasping bag. 
Dilating bags of different shapes and sizes 
(Barnes, Champetier de Ribes and 
Pomeroy's). 
Piston or Davison syringe for filling bag. 
Weight for attachment to bag. 
As rubber rapidly deteriorates, the nurse must test 
each bag immediately before use to make sure that it 
is water-tight. After being inserted, the bag is filled 
with sterile water by means of the syringe. When 
fully inflated, the syringe is removed, the stop-cock 
turned, a weight attached to the bag and hung over the 
foot of the bed which is elevated. 

Insertion of Bossi's Dilator. — This is a powerful instru- 
ment used for artificial dilatation of the pregnant uterus. 
Instruments required : 

Weight speculum. 
Vaginal retractors. 
Two volsellum forceps. 
Bossi's dilator. 
Packing the Uterus for Hemorrhage. — Instruments 
required : 

Weight speculum. 
Vaginal retractors. 
Two volsellum forceps. 



140 



OBSTETRIC NURSING 



Long packing forceps. 

Folded packing, ij inch wide, in strips 3 
yards long. 
Forceps Delivery. — Prepare the patient in the usual 
way; catheterize when under ether. Instruments 
required : 

Obstetrical forceps (plain or axis-traction). 

Glass vaginal nozzle. 

Glass intrauterine nozzle. 

Outfit for perineal repair. 




Fig. 38. — Elliott's Modification of Simpson's Forceps. {Edgar.) 



Provide a sterile douche-bag filled with sterile salt 
solution at 115 for vaginal or intrauterine irrigation, 
if required. Prepare a tub of hot water to be used for 
the baby, if it arrives asphyxiated. Be sure to wipe 
the baby's eyes off with boric acid solution as soon as 
the head is born. 

Version or turning of the child is an operation which 
requires no instruments. Prepare the patient in the 
usual manner, have her hips drawn well over the edge 
of the bed or table and be sure that the bladder is 
empty. 



OBSTETRIC OPERATIONS. 141 

Manual Extraction of the Breech. — This requires 
rapid work on the part of the doctor after a certain 
point in the delivery is reached. The patient's hips 
must be well over the edge of the table. If the child 
appears large, forceps should be in readiness and in- 
struments for perineal repair — it may be necessary to 
apply forceps to the after-coming head. 




Fig. 39. — Tarnier's Axis-traction Forceps. {Edgar.) 

Pubiotomy. — An operation to enlarge the bony pelvis 
by sawing through the left pubic ramus subcutane- 
ously. This operation is performed when dilatation is 
complete. After the patient has been put to the test of 
labor and has demonstrated her inability to force the 
child's head through the pelvic brim she is prepared 
for operation as above described with particularly 



142 OBSTETRIC NURSING. 

careful disinfection of the lower abdomen and pubic 
regions; she must be carefully shaved. Instruments 
required : 

Pubiotomy needle. 

Gigli wire saw. 

Handles for wire saw. 

Axis-traction forceps. 
The patient is placed in the lithotomy position and 
catheterized. The pubiotomy needle is inserted under 
the ramus of the left pubic bone, passed behind it and 
brought out close to its upper border. The Gigli saw 
is threaded in the needle which is withdrawn bringing 
the saw with it ; handles are attached to the saw and, by 
traction upon these, the bone is rapidly sawn through 
permitting a separation of 4 to 6 centimeters with 
safety. Pressure is immediately applied on the sub- 
cutaneous incision, forceps are applied to the child's 
head and extraction proceeded with. After delivery 
a large pad of sterile gauze is applied over the cut pubic 
bone and in the vagina while the hips are firmly 
strapped with broad pieces of adhesive plaster. The cut 
bone unites firmly by cartilage which usually stretches 
sufficiently at a subsequent confinement to permit 
spontaneous delivery. 

Classical Cesarean Section. — By this operation, the 
child is delivered through an incision in the abdominal 
wall and uterus. It is resorted to when the bony pelvis 
is so contracted that delivery through it is impossible, 
when cancer of the cervix or fibroid tumors prevent de- 



OBSTETRIC OPERATIONS. 



143 



livery by the vaginal route, and sometimes for placenta 
praevia. 

The preparation of the patient, room, dressings and 
supplies is the same as for any abdominal operation; 




Fig. 40. — Smellie's Scissors Perforator. {Edgar.) 

in addition, everything must be in readiness for resus- 
citation of the baby. Instruments required : 

Two scalpels. 

Three pairs scissors; two short, straight, one 
curbed peritoneal. 




Fig. 41. — Braun's Cranioclast. {Edgar.) 

Two double tenacula. 
Twelve sponge forceps. 
Four long straight clamps. 
Two long curved clamps. 



144 OBSTETRIC NURSING. 

Two tissue forceps. 

Two abdominal retractors. 

One uterine packing forceps. 

Two needle-holders. 

Eight full-curved round needles. 

Four full-curved cutting-edge needles. 

Two subcuticular needles. 

Suture material: Braided silk, Nos. 2 and 3. 
Plain catgut, Nos. 1 and 2. Chromicized 
catgut, Nos. 1 and 2. 
Craniotomy. — Perforation of the child's head and ex- 
traction of the mutilated head and body by means of 
the cranioclast is sometimes necessary for the delivery 
of a large dead child. Instruments required : 

Perforator. 

Cranioclast. 



CHAPTER XIV. 

MANAGEMENT OF THE LYING-IN. 

Immediately after the delivery it is necessary that 
the patient should have rest. The room should be kept 
exceedingly quiet and the shades drawn down so as to 
subdue the light. 

The patient may be allowed to sleep, but the nurse, 
during this time, should watch her very carefully, as 
there is a liability to bleeding when the sleep is too deep, 
owing to the general relaxation induced by sleep. She 
should draw the bedclothes up at one side from time to 
time, to see how much blood is lost. 

There should be no unpleasant smell about a confine- 
ment room, plenty of fresh air should be allowed to 
enter, and all discharges should be at once removed 
from the room. 

While the patient sleeps, and after the child has re- 
ceived proper attention, the nurse should place the 
soiled sheets, towels, and all articles stained with blood in 
cold water to soak. 

The afterbirth, also, should be disposed of. If in the 
country, it should be buried in a hole dug in the yard, 
two or more feet deep. It should never be thrown 
down a water-closet or privy. In the city it is best to 
burn it at night. It may be put in the range or stove 

10 145 



I46 OBSTETRIC NURSING. 

and well covered up with coals. Clots of blood may 
safely go down the water-closet, as they readily dissolve. 

To return to the soiled clothing left after a confinement 
— though a trained nurse will not often be called upon 
to attend to the washing of these articles, there will be 
times when it would be better that she should do so, 
both to save the patient expense and trouble and to 
prevent their lying about too long. At any rate, she 
should know how it should be done. Should the cloth- 
ing be put to soak before the blood has dried into it, 
and allowed to remain for a few hours, the water being 
changed as often as needed, the washing will not be 
difficult. 

As a rule, it is not best that a nurse should leave her 
patient or the baby long enough to attend to this wash, 
hence it is advisable to have it put out or done by some 
one else in the house. The soaking ought, however, 
always to be attended to by the nurse, because it facili- 
tates the subsequent washing. 

In the after-care of the patient the nurse should attend 
to the washing of the mother's and baby's napkins. She 
should, if needed, wash the baby's flannels and slips. 

Visitors. — For a week a newly-confined patient should 
see no visitors. Even the husband should not remain 
in the room long at a time. No painful or exciting news 
should be communicated to the patient, as a distressing 
form of mental trouble to which lying-in women are 
prone maybe thus induced. This is known as "puer- 
peral mania." 



MANAGEMENT OF THE LYING-IN. 147 

Food. — After the patient rouses from her first sleep 
she is generally hungry. The nurse should have learned 
from the physician before he left what he would prefer 
her having. A cup of warm milk or tea — not too hot — 
may be given directly after the confinement when ether 
has not been taken, and this followed in three or four 
hours by a light meal, as toast and tea or gruel. With 
regard to the diet of the lying-in, nurses must be pre- 
pared to follow the rules of the physicians for whom 
they work. Some physicians allow considerable variety 
in the food from the beginning. 

The following directions concerning the diet are given 
to the nurses of the Woman's Hospital : "It should be 
remembered, in the diet of the lying-in woman, that the 
amount of liquids, should the breasts or nipples threaten 
to give trouble, must be limited, not only until after the 
secretion of milk, but also until the supply of milk adapts 
itself to the demand, for the first five or six days after 
the confinement. 

As soon as the patient is made comfortable after the 
birth, she should have a cup of warm milk or weak tea, 
or warm water and milk. 

First meal-time: Plate of milk toast or bowl of 
oatmeal gruel, or saucer of wheat germ or boiled 
rice. 

Second meal: Cup of weak tea or warm milk, dry 
toast, or milk toast, or water toast, or soda crackers 
soaked in hot milk. 

Third meal: Saucer of oatmeal mush or wheaten 



I48 OBSTETRIC NURSING. 

grits, with a cup of tea or warm milk, with Graham 
biscuit or dry toast. In normal cases a little stewed 
fruit may be given with the evening meal, even on the 
first day. 

Forenoon, afternoon, bedtime: Lunch, a cup of 
warm milk, with a piece of dried bread or Zwieback. 

Second Day. — The same as above. 

Third Day. — The same, with the addition of stewed 
apples or baked apples for supper, if not given before. 

Fourth Day. — Breakfast: Soft-boiled egg, dried 
bread, stewed fruit, and cup of milk or weak tea. 

Dinner: Plain beef or mutton-broth, dried bread, 
and farina or junket. 

Supper: Baked apples or stewed prunes, saucer of 
wheat germ, and Zwieback. 

Fifth Day. — Breakfast: Cup of weak coffee or 
cocoa, mutton-chop, oatmeal mush, dried bread, and 
a sweet orange or ripe apple. 

Dinner : Beef or mutton-broth or oyster-stew, baked 
potato, stewed tomatoes, dried bread, farina, junket, or 
rice. 

Supper: Stewed fruit, Indian-meal mush, and 
Zwieback. 

Sixth Day. — Ordinary plain diet, avoiding salads, 
sour fruit, fried or highly-seasoned meats, fancy desserts, 
or sweets of any kind. 

This holds good of all subsequent meals. The above 
dietary will require to be modified when special indi- 
cations arise. Should the patient's temperature rise to 



MANAGEMENT OF THE LYING-IN. 149 

ioo° Fahr., or above, she should be kept on liquid diet, 
as milk and beef -tea alternately every two hours until 
the physician directs otherwise. 

As liquids favor the secretion of milk, liquid food 
should constitute a large proportion of the nourishment 
taken by nursing women throughout the lying-in, pro- 
vided there is not a tendency to over-secretion. The 
diet should be plentiful and nutritious, but selected care- 
fully with reference to its digestibility. As the patient 
must remain inactive for some time, it will not do for 
her to eat the starchy vegetables, pastry, or warm 
breads, for all these require very active powers of 
digestion. 

A nurse should thoroughly understand the art of 
cooking, and be able to provide her patient with pala- 
table and nutritious dishes, daintily and prettily served 
on a tray, until, with the physician's consent, she takes 
her place at the family table. Even then a nursing 
woman will need to receive some nourishment, as gruel, 
beef -tea, milk, etc., between the regular meals, for she 
must not only provide for herself, but for her child. 

Duration of Lying-in. — The lying-in lasts six weeks. 
During this time the organs of generation are returning 
so far as possible to their former condition. It is im- 
portant that the patient should have rest, and for at 
least two weeks of this time should be in bed. 

Involution. — The process of changes by which the 
womb shrinks to its normal size is known as "involu- 
tion" This process is favored by the patient lying as 



150 OBSTETRIC NURSING. 

much as possible on her back, so that the womb does 
not incline too much to one side or the other. The 
patient may be carefully propped up a little by pillows 
on the third or fourth day, so that she shall be in a semi- 
reclining position. This facilitates the drainage of the 
uterus. Care must be taken not to permit her to move 
herself too much, as a hemorrhage may be thus started. 
The progress of involution is determined by the height 
of the uterus as appreciated by palpation over the 
lower part of the abdomen. Under the most favorable 
conditions the uterine fundus will be found to corre- 
spond in height with the following points : 

Twenty-four hours after labor, — on a level with the 
umbilicus. 

Second and third day, — midway between umbilicus 
and symphysis pubis. 

Fifth and sixth day, — three fingers' breadth above 
the pubic symphysis. 

Ninth and tenth day, — on a level with the pubic 
symphysis. 

A full bladder or a full rectum will prevent proper 
contraction and decrease in size of the uterus, as also 
will subinvolution from former uterine disease of any 
kind, or from inefficiency of the uterine muscular tissue. 

The Lochia. — The discharges of the mother con- 
tinue about two weeks, and they are called the "lochia" 
For the first twenty-four hours they are blood; the 
second and third day, watery blood ; from the fourth to 
the sixth day they have a greenish-yellow coloration, 



MANAGEMENT OF THE LYING-IN. 151 

and from the tenth to the twelfth day they become 
white . This white discharge may continue for a long time 
after the confinement. The character of the discharge 
will indicate the process of involution, hence the phy- 
sician should see daily the napkins or dressings 
removed from the patient. Soiled napkins and dressings 
should never be kept in the patient's room, but in some 
closed vessel, as a clean chamber or a slop jar, with a 
close-fitting lid, in another room. The existence of the 
least odor about the discharge should at once be brought 
to the physician's attention. If napkins are used, 
they will need to be changed during the first day about 
every two hours, sometimes oftener ; the second and third 
day, about every three hours: the fourth and fifth day, 
every four hours; until, by the tenth day, about three 
changes are sufficient. The antiseptic dressings are 
changed, as a rule, every three hours until the discharge 
ceases. If it be very scant, a change once in six hours 
may be sufficient. These antiseptic dressings should be 
burned. The napkins should be soaked in cold water 
until the blood is well out of them, and then thoroughly 
washed and boiled. The boiling is sufficient, if prop- 
erly done, to render them aseptic, but, as an additional 
precaution, they may be wrung out in a 1-2000 bi- 
chloroid solution before drying. The patient should 
be washed off each time the napkin is changed with a 
warm antiseptic solution, as 1-4000 of the bichlorid of 
mercury, or a lysol solution of 1 per cent. Care should 
be taken not to irritate the parts. Instead of using 



152 OBSTETRIC NURSING. 

a soft cloth to wash off the parts, the water may be 
poured in a small stream over them, and a soft, dry 
cloth pressed gently over them to remove all moisture. 
Especial care should be taken where there are stitches 
not to pull them in any way. 

Bathing. — One daily washing of the entire body is, 
as a rule, desirable. The doctor's advice, however, 
should be asked concerning the matter. This wash, 
when given as a sponge-bath, need not exhaust the 
patient, nor cause too much movement of her body. 

The patient should never feel chilly during this bath ; 
should she do so, the bath must at once be stopped. 

The bath should, of course, be given under cover. 
The increased activity of the skin necessitates 
especial cleanliness, and the daily bath is found, when 
properly given, to be very refreshing. Frequent 
changes of bed and body clothing, too, are necessary — 
the body clothing, if possible, daily until the dis- 
charges cease. 

Attention to Bladder. — The bladder is frequently 
paralyzed after confinement, as a result of the 
pressure to which it has been subjected during 
labor. When it is filled beyond a certain limit, it 
may respond to the irritation and a little urine 
be voided, but the bladder not be emptied. The 
nurse can tell by the amount passed whether the 
patient has probably emptied the bladder or not. 
The secretion of urine early in the lying-in is very 
free, hence the quantity passed should never be scant. 



MANAGEMENT OF THE LYING-IN. 153 

By placing the hand over the lower part of the 
abdomen, the bladder may be felt as a soft tumor 
on one or the other side, above the pubic bone, the 
womb being felt as a harder mass pushed to the 
opposite side. 

The catheter should not be used without the physi- 
cian's sanction, but a nurse should never forget to ask 
very particularly about this matter before he leaves the 
house after the delivery. It is generally undesirable 
to allow a patient to go longer than six hours without 
freely emptying the bladder. As over-distention of the 
bladder prevents proper contractions of the womb, and 
as a relaxed womb is a frequent cause of after-pains, 
it is best to have the bladder quite frequently emptied 
during the first twenty-four hours. Hence, if the 
catheter is permitted to be employed, it may be well 
to use it about three hours after delivery for the first 
time (the physician having used it, if necessary, imme- 
diately after delivery). Its subsequent use should be 
limited to about once in six hours, unless its more fre- 
quent use is demanded by the interference with the 
contractions of the womb caused by over-distention of 
the bladder. The patient should be encouraged to 
make a trial to urinate as soon as possible, so that the 
use of the catheter may be entirely dispensed with. 
Great care is necessarv in the use of the catheter: ist, 
to see that the instrument is throughly clean and kept 
clean; 2d, to see that none of the vaginal discharges are 
carried into the bladder during its introduction; 3d, 



154 OBSTETRIC NURSING. 

to do no injury to the mother's parts or give her 
needless pain. 

The instrument, a glass catheter, should be thor- 
oughly boiled if there is any doubt about its being 
aseptic. 

When withdrawing it the outer extremity should be 
kept lowered, so that all the urine remaining may 
flow out from it, and no sediment settle in the 
closed end to become a source of contamination at 
some future time. It should then be thoroughly 
washed in hot water, w T hich should be allowed to flow 
through it from the inner toward the outer extremity, 
carrying out any sediment fro'm the urine, and it may 
be kept during the intervals of its use in an antiseptic 
solution — a two per cent, solution of creolin, carbolic 
acid, or lysol. To prevent the carrying of the vaginal 
discharges into the urethra the parts should be care- 
fully washed off with an antiseptic solution, either by 
irrigation or by means of a soft cloth, before the 
insertion of the catheter. 

Difficult Micturition. — For the first twenty-four to 
forty-eight hours after delivery, particularly if the 
labor has been a difficult one, there is a considerable 
swelling of the parts which offers a mechanical hindrance 
both to voluntary urination and the passage of the cathe- 
ter. Great gentleness is therefore required in the neces- 
sary manipulations. This swelling in an ordinary case 
should disappear at the end of twenty-four to forty- 
eight hours. Should the inability to urinate persist 



MANAGEMENT OF THE LYING-IN. 1 55 

after this, it is in all probability due to the condition 
of paralysis before referred to. Especial medication 
by the physician, as the use of muscle and nerve tonics, 
fomentation over the lower part of the abdomen and 
external generative organs, hot water in a bed-pan, 
placed beneath the patient's hips, may serve to stimu- 
late voluntary urination. The attempt to induce this 
should be made each time before a resort to the catheter, 
as the constant use of the latter will only keep up 
the difficulty. 

Constipation. — Constipation due to paralysis of 
the bowels caused by the pressure of the gravid 
womb upon the bowels is very marked during the 
lying-in. 

It is desirable to have the bowels moved by injection 
before the end of the first twenty-four hours, and, 
thereafter, to secure a daily movement by such means 
as may be recommended by the physician in attend- 
ance. Regulation of the food will do much to correct 
the habit of constipation, as a laxative diet 
composed mainly of brown bread, oatmeal gruel, 
prunes, etc. An occasional enema of warm soapsuds 
may be needed, or from a teaspoonful to a tablespoonful 
of glycerin may be injected into the lower bowel, or a 
glycerin or gluten suppository be given. If these 
means do not suffice, some medication may be needed. 
The laxative chosen by the physician will depend 
upon the condition of the breasts, as well as its liability 
to affect the milk. 



156 OBSTETRIC NURSING. 

Should the breasts be over-distended, a saline 
laxative will be. preferred. Thus, two teaspoonfuls of 
Rochelle salts in a half -tumblerful of cold water may 
be given, an additional tumblerful of pure water being 
taken after it. Sulphate of magnesia or Epsom 
salts may be used in the same way, or a teaspoonful 
of cream of tartar may be taken night and morning in 
a cup of sweetened water. 

When the secretion of milk is scanty, a vegetable 
laxative is to be preferred, as rhubarb, aloes, or cascara 
sagrada. 

At times there is such impaction of the contents of 
the lower bowel that an oil injection will be needed. 
A gill of cotton-seed oil may be introduced into the 
lower bowel and retained for three or four hours, after 
which a small soap and water injection will lead to a 
thorough evacuation of the bowel. 

The Care of the Nipples and Breasts is very 
important. If this matter has received proper 
attention during the pregnancy, there will be compara- 
tively little trouble during the lying-in. It is important 
to keep the nipples clean. Milk should not be allowed 
to collect about them, hence immediately after nursing, 
while they are swollen and soft, they should be washed ; 
a soft piece of linen may be used and cold water, or a 
saturated solution of boric acid, after which they may 
be dried with a soft cloth. This should be repeated 
after every nursing. 

If the skin of the nipple be unusually thin, it is 



MANAGEMENT OP THE LYING-IN. 



157 



best to avoid having the baby pull directly upon the 
nipple until the milk flows freely, hence a nipple 
shield should be used, at least for the first two or three 
days, if not longer. 

Should the nipple become sore at any time,the nipple 
shield should again be resorted to and used until the 
sore is healed. 

Some application, as a ten per cent, solution of tannic 
acid in tincture of myrrh, balsam of Peru, or a weak 
solution of nitrate of silver, according to the order of 
the physician, may be painted with a sterile cotton 
stick brush over the cracks in the 
nipple while it is soft and swollen, 
immediately after nursing. A very 
healing application consists of a 
paste made of equal parts of bismuth 
subnitrate and castor oil. This can 
be kept constantly applied in the 
intervals of nursing. This may be 
wiped off when the time for nursing 
arrives, but need not be entirely re- 
moved, as it cannot hurt the babv. 
This paste or the application of a 
little oil or cold cream to tender nipples will often 
prevent their cracking. 

For any nipple shield to work perfectly it must fit 
tightly, hence an entire rubber shield is not so good 
as some others. Some shields are made of part metal 
and part rubber, others part rubber and part glass. 




Fig. 42. — Nipple 
Shield. 



158 OBSTETRIC NURSING. 

The cheapest are the ordinary glass shields with 
rubber nipples. They cost about fifteen cents and are 
quite as good as those that are higher priced. 

A shield is not good if it allows the nipple to be 
drawn out too far. In the intervals of nursing the 
rubber nipple should be kept in cold water after having 
been turned inside out and thoroughly cleaned with a 
brush. 

Nipple protectors are worn only in the intervals of 
nursing, or during pregnancy, for shaping the nipple. 1 
These may be made of lead, glass or wood. Leaden 
protectors keep the nipples soft in the intervals of 
nursing, and have a healing effect upon the abrasions 
and cracks of a tender nipple. Unless care be taken, 
however, to cleanse the nipple thoroughly before the 
baby nurses, there is danger of lead-poisoning. Nipple 
protectors of glass and wood, being open at the top, are 
intended more to keep the clothing of the patient off the 
tender nipple. 2 The nipple may, in addition, be kept 
moist in the intervals of nursing by the application over 
it of a cap of absorbent cotton saturated with equal 
parts of glycerine, listerine and water. 

Shape of Nipples. — Nipples vary much in shape — 
thus they may be cone-shaped, hollow, mushroom- 
shaped, and depressed. 

^ee Fig. 17, page 50. 

2 There is a form of nipple protector made of glass which also acts as 
a reservoir to catch the overflow of milk in cases where it flows involuntarily 
from the nipple. This is useful in preventing the constant wetting of the 
patient's clothing. 



MANAGEMENT OF THE LYING-IN. 1 59 

The cone-shaped nipple is the best, as it can be 
readily seized by the child's mouth, and the pressure 
of the baby lips does not constrict the nipple at its 
base, so as to prevent the free escape of milk from the 
mouths of the milk ducts which open at the top of 
the nipple. The mushroom-shaped nipple has so narrow 
a base that the free flow of milk may be thus prevented. 





CONE-SHAPPED. HOLLOW, 




Mushroom-shaped. Depressed. 

Fig. 43. 

The hollow nipple is apt to get sore from two 
causes: first, by the forcible suction made by the child 
in emptying the breast; second, by the accumulation 
of milk in the depressed portion of the apex. 

The depressed nipple differs from the last class in the 
fact that there is no elevation of the nipple above the 
surface of the breast, but where the nipple should be 
there is a corresponding depression. Very little may 
be done for such a nipple, and all efforts to make a 



l6o OBSTETRIC NURSING. 

nipple by drawing it out must generally be abandoned, 
as they only irritate the tender skin. 

Bandaging of Breasts. — It is best when nipples of 
this class exist to abandon the idea of nursing the 
child, and prevent the accumulation of milk in the 
breasts by bandaging. This should also be done where 
there is a previous history of breast abscess — the 
breast affected being thus bandaged to prevent the 
attempt at secretion by the gland. 

The firmest bandage is the figure-of-eight of the breasts, 
which may be applied to one or both of the breasts 
according to need. If it cannot be used, the wide, 
straight bandage, similar to an abdominal bandage, 
may be employed, or the straight bandage with straps 
to fasten it over the shoulders, according to the pattern 
shown in Fig. 28. Were the milk permitted to accu- 
mulate in the breast, and there be no ready outlet for 
it,' 'caked breast" would be apt to ensue. 

"Caked Breast" is caused by a collection of milk 
in one or the other part of the breast, due to blocking 
up of a milk-duct. The indications for its relief are 
to empty the breast. The milk may be drawn out 
by a baby if there be a proper nipple, or by the use of the 
breast-pump. 

The breast may be gently rubbed with warm oil and 
stroked from the base toward the nipple to aid in 
carrying the milk toward the mouths of the milk-ducts. 
Camphor liniment is sometimes used as an inunction, 
alone or combined with laudanum ; but unless it is the 



MANAGEMENT OF THE LYING-IN. 



161 



intention to help to dry up the milk, camphor should' be 
avoided. 

The use of fomentations before rubbing greatly helps 
to soften up the breast. By fomentations is meant 
the application of flannels wrung out in hot water, 
constantly changed as they cool. These applica- 
tions should be continued for fifteen to twenty 
minutes at a time. After their use if the baby be put 
to the breast or the breast-pump be used, the milk will 
generally flow quite freely. 

A new method for the relief of congested breasts is the 
application of Bier's suction hyperemia for ten minutes 
two or three times a day. 




Fig. 44. — Breast-Pump. 



Breast -pumps. — Those breast-pumps are the best 
which depend for suction on the power of the mouth. 
The Phoenix breast-pump is the one generally preferred. 

They may be used by the nurse, or a patient 
may use such a pump herself should a nurse not be 
present. Hand-pumps are not good, as too much force 



11 



1 62 OBSTETRIC NURSING. 

is apt to be used- in making suction — the nipple may 
thus be torn off. Where a breast-pump cannot be had, 
a simple contrivance may be resorted to for emptying 
the breasts which is often very effective. A bottle 
filled with very hot water may be emptied of its con- 
tents, and while still hot the mouth of the bottle closely 
applied over the nipple. As the bottle cools, the 
nipple is drawn up into the neck of the bottle, and the 
flow of milk induced. 

Pendulous Breasts. — When the breasts are pendul- 
lous, handkerchief bandages, properly applied, make 
a good support. 

Their application is as follows: "The base of the 
handkerchief, folded as a triangle, should be placed 
obliquely across the chest and under one breast, with 
the apex or summit of the triangle over the correspond- 
ing shoulder; one angle is carried over the opposite 
shoulder, the other under the axilla, or armpit, of the 
same side. These ends should be tied on the back 
of the shoulder, and the apex of the triangle pinned to 
them." (Smith.) 

Should both breasts need support, a similar bandage 
may be applied to the other breast. To prevent the 
base of one or both of these bandages from slipping up, 
the ordinary handkerchief bandage has been modified 
in the Woman's Hospital by the addition of a belt 
around the waist, of a strip of muslin or ordinary roller 
bandage, to which the base of the bandage may be 
fastened by safety-pins. 



MANAGEMENT OF THE LYING-IN. 163 

A simple straight bandage, with a compress to lift 
the outer, pendulous portion of each breast, is some- 
times used, darts being employed to shape it properly 
to the person. This makes a firmer support than the 



Fig. 45. — Worcester's Y-Bandage. 
The upper figure shows the double- Y breast bandage in position; the 
lower left-hand figure shows how the bandage is made. The third figure 
shows how the double- Y bandage is completed by fastening the arms of the 
Y to the tailpiece on the patient's opposite side. 

handkerchief bandage . It should be made of unbleached 
muslin or some firm material. 

Another bandage, which has the advantage of not 
requiring to be removed when the baby nurses, is the 



164 OBSTETRIC NURSING. 

double-Y bandage, used in the Boston Lying-in Hospital. 
The manner of putting it on is thus described by Dr. 
Worcester: " A single T-bandage is first made by fold- 
ing a napkin lengthwise so that for an average-sized 
patient it shall be 32 inches long by 3 inches wide. At 
the middle of this, and at righ angles to it, is pinned, 
just between its folds, a napkin of the same size, simi- 
larly folded. This T-bandage is next made into a 
Y-bandage, by making a diagonal fold in the middle 
of the cross-piece and fastening the corners of the plait 
with safety-pins on the outside. The bandage is now 
ready to put on. The tail-piece is passed under the 
woman's back, snug up to her armpits, so that the 
fork of the Y just clears one nipple when that breast 
is held upward and inward on the chest. The tail- 
piece on the other side is carried up 
on the chest directly over the breast. 
The arms of the Y are then 
brought over the chest, one above 
and the other below the breasts, and 
their ends pinned to the tail-piece, 
Fig' 46.— Obstetrical so as to hold both breasts in similar 

Breast Support, with pos ition. A Compress of soft linen 
Knitted Bosoms. r r 

may be placed between the bandage 
and the outside of the breasts, and also between the 
breasts, to prevent their chafing. To keep the bandage 
from slipping down, straps of muslin may be passed 
over the shoulders and pinned back and front. To 
keep it from slipping up, it may be fastened to 




MANAGEMENT OF THE LYING-IN. 165 

the abdominal bandage." The bandages referred to 
are very useful while the patient is in bed, but when 
she begins to sit up and wear ordinary clothing they 
will be found to be cumbersome. Some such breast 
support as is shown in Fig. 46 may then be found very 
useful. 

Gathered Breasts. — There is nothing in the care 
of a lying-in patient for which a nurse receives 
more blame than in the occurrence of gathered breasts. 
Abscesses will sometimes ocgur, however, in spite of all 
precautions, even before confinement. Extreme watch- 
fulness and a prompt reporting of any symptoms of 
beginning trouble, as chilliness, hardness of the breasts, 
sore nipples, etc., will do much to avert them. It must 
never be forgotten that sore nipples, by offering an open 
surface upon the mother's body, may become avenues 
of septic infection. Dirty hands or dirty garments touch- 
ing these surfaces or poison from the baby's mouth may 
thus enter the mother's system. One of the most seri- 
ous forms of inflammation of the breast may thus 
result from blood-poisoning. If the breast has once 
gathered, there will be a tendency for it to gather 
again . Should an abscess threaten by beginning inflam- 
mation of the breast, the treatment will, of course, be 
directed by the physician. What milk is in the breast 
must be drawn out, and some means used to prevent 
further secretion. The use of an ice-bag to arrest ten- 
dency to inflammatory involvement is advised by some, 
the breast being at the same time elevated and com- 



1 66 OBSTETRIC NURSING. 

pressed by a bandage. Belladonna breast-plasters were 
at one time much used, the circular breast-plasters being 
obtained at any drug store. The belladonna ointment 
spread on patent lint, shaped to the breast is preferred 
by some physicians. Simple compression of the breast by 
a firm bandage is generally sufficient, without the aid 
of other measures, in the checking of the secretion 
after the breast has been emptied. 

Should the breast gather, lancing is inevitable, and 
the sooner the better, so that a nurse should keep the 
physician carefully informed as to the condition of the 
breast. Flaxseed poultices or, far better, antiseptic 
poultices (consisting of several layers of sterilized gauze 
wrung out of hot sterile water and covered by gutta- 
percha tissue) , may need to be applied for a time, both 
before and after lancing. These poultices, to do any 
good, should be applied as hot as possible. The nurse can 
test the heat of the poultice by laying her cheek against 
it. If she- can bear this application without finding it 
too hot, the patient will also probably be able to bear it. 
If the poultice be made of flannel it will not lose its heat 
as quickly as when made of muslin. The poultices will 
require changing about once in two hours, or often 
enough to keep them warm ; and should be kept up until 
the abscesses point and are evacuated. The nurse 
should encourage the patient to have an abscess lanced, 
and should have prepared, at the time of the operation, 
the antiseptic solution preferred for the physician's 
hands and for washing out the abscess canity, a syringe, 



MANAGEMENT OF THE LYING-IN, 



167 



if possible, a pus-pan having a concave side to fit closely 
under the breast, some narrow folded gauze packing or 
drainage tubes of rubber, soft towels, and some absorb- 
ent cotton to be used in place of sponges for cleansing 
the breast. Before the operation, the breast should be 
washed off with an antiseptic solution. Between the 
applications of the different poultices the breast should 
be similarly washed off by the nurse. The physician 
will probably desire to wash out the abscess cavity daily 
so long as the discharge of pus continues, in which case 
the nurse should have everything in readiness at the 
time of his expected visit. 




Fig. 47. — Bier's Hyperemia Apparatus for Mastitis. 

Biers suction hyperemia is of great benefit in the after 
treatment of breast abscesses. At the second or third 
dressing, drainage tubes and packing may be removed 
and the breast bell applied. Hyperemia is induced for 
five or six, five-minute periods with pauses of a minute 



1 68 OBSTETRIC NURSING. 

between. The intermittent suction thoroughly empties 
the abscess cavity rendering irrigation and packing un- 
necessary, while the artificially induced hyperemia stim- 
ulates the processes of repair. 

Galactorrhea. —Sometimes milk runs constantly from 
the breasts. Much may be done to prevent this by regu- 
lar nursing. If it persists, the amount of liquid in the 
food should be restricted. Sometimes the milk runs 
from the opposite breast while the baby is nursing at 
one. There is no way to prevent this. Some mothers 
collect it as it drops in a small bottle or cup and feed it 
to the baby. 

Insufficient Milk. — If the mother has only sufficient 
milk for half the day, the baby had better be artificially 
fed by day, the breast milk being reserved for the night, 
as giving less trouble when the care of the child devolves 
upon her. 

After-pains are the same as labor-pains, being caused 
by contractions of the womb. They are called after- 
pains because they occur after confinement. A woman, 
after the birth of her first baby, seldom has after-pains. 
They may occur with varying severity in women who 
have previously borne children. If the bladder and the 
bowels are properly attended to, and the womb kept 
well contracted, the patient is not likely to suffer much 
from after-pains. 

These pains seldom last over the second day. Should 
they do so, it is probable that the patient is threatened 
with some inflammation. 



MANAGEMENT OF THE LYING-IN. 1 69 

The occurrence of after-pains should, of course, be at 
once reported to the doctor, and such measures for relief 
carried out as he may suggest. 

The womb will be found to be in two entirely different 
conditions with the occurrence of these pains. Hence, 
we divide the pains into two classes, the "expulsive" 
and the "spasmodic" or "neuralgic." 

With expulsive after-pains the womb, as it is felt 
through the abdominal walls, will be found to be large 
and soft, and the patient will often pass clots. The 
bladder will be frequently found to be over-full and the 
womb pushed high up or to one side. The indications 
are to empty the bladder and to secure good contractions 
of the womb. After the bladder is emptied the pain 
may be relieved by the application of a hot poultice over 
the lower part of the abdomen, and fluid extract of ergot 
may be given, if desired, by the physician (1/2 teaspoon- 
ful every three hours) , until the womb is well contracted. 
A nurse should never give any medicine without the 
direction of the physician. Before entire relief is ob- 
tained it may be necessary for the physician to break 
down and wash out the clots within the womb. 

Intra-uterine Injection. — The nurse should slip drawers 
and stockings on the patient in preparation for this 
operation, as she may need to lie across the bed with her 
hips drawn to its edge. A bed-pan, syringe, antiseptic 
solutions, receptacle for waste water, and rubber pro- 
tective for bed and floor should be prepared. 

When spasmodic after-pains occur, the womb is felt in 



170 OBSTETRIC NURSING. 

the lower part of the abdomen as a firm, round ball of 
stony hardness. This is caused by a spasm of the mus- 
cle fibers in the womb. The remedies which would help 
expulsive pains would only aggravate this condition. 
Something must be employed which will quickly relax 
the spasm. The most efficient agent is chloroform lini- 
ment, which may be applied on flannel over the lower 
part of the abdomen. The acute counter-irritation thus 
produced will give relief. Should the spasm be very 
severe, the physician may apply pure chloroform sprin- 
kled on blotting-paper, for a few seconds, over the lower 
part of the abdomen until it well reddens the skin. 
Should no chloroform liniment be at hand, a warm 
flaxseed poultice may help to some extent, though not 
so efficient, as a rule. 

A Careful Report should be kept by the nurse, from 
which the physician can learn all that has transpired in 
the intervals between his visits. 

Sheets of paper, ruled and having headings, as in the 
accompanying diagram, are used in the Woman's Hos- 
pital. 

Observation of Symptoms. — The occurrence of pain, 
any complaint of chilliness or a decided chill, rise of tem- 
perature, rapid pulse, sleeplessness, headache, want of 
appetite, etc., should be carefully noted and brought to 
the physician's attention. 



MANAGEMENT OF THE LYING-IN. 



171 






^3 

fe: 



REMARKS. 


• 


BOWEL 

MOVEMENT. 




URINE. 


MEDICINE AND TREATMENT. 




FOOD. 




RESP. 


0< 




PULSE. 


* 


HOUR. 


W 
Eh 

P 





172 OBSTETRIC NURSING. 

For the first week or ten days it is well to take the 
temperature and pulse in the morning, at noon, and in 
the evening; after which, if the patient is doing well, the 
morning and evening temperature and pulse will be 
sufficient. 

Should the slightest complaint of chilliness be made, 
the nurse should place extra covers around the patient, 
hot-water bottles, if necessary, to warm her up, and at 
the same time give her a warm drink, as a cup of hot tea, 
or e^en hot water. 

The temperature should always be taken after a com- 
plaint of chilliness, and taken quite frequently, as every 
hour or two, when, if it be found to be rising, anote should 
at once be sent to the physician, who may want, under 
the circumstances, to see the patient at once or to insti- 
tute some new line of treatment. Pain may be tempor- 
arily relieved by the application of a hot flaxseed poultice . 
Grave inflammatory and septic troubles are ushered in 
by such symptoms as the above, hence no time should 
be lost in notifying the physician of their occurrence. 

Puerperal Fever. — The use of blisters, poultices, 
packs, vaginal injections, and medicinal remedies re- 
quired in the treatment of the various forms of " puer- 
peral fever ' ' must, of course, be in exact accordance with 
the physician's directions. 

Such troubles are generally septic — that is, arise from 
blood-poisoning; and one very important duty of the 
nurse will be to see that the patient takes sufficient 
nourishment to combat the poison in the blood. 



MANAGEMENT OF THE LYING-IN. 173 

Stimulants should never be given without a physician's 
advice, but when ordered great care should be exercised 
in their faithful administration. Egg-nog, milk-punch, 
whiskey-punch, wine-whey, milk in the various liquid 
and semi-liquid preparations, beef-tea, broths, etc., will 
be called for. The nurse should be ready with devices 
to tempt her patient to eat, and thus give the most im- 
portant aid to the arrest of the disease. The support of 
the strength, with extreme cleanliness and thorough 
antisepsis, will do much to arrest the course of the ter- 
rible maladies due to blood-poisoning. 

Puerperal Ulcers. — The existence of any sores about 
the vulva or vagina, when discovered by the nurse, 
should at once be reported to the doctor. These are 
especially dangerous when they take on a grayish sur- 
face, as this indicates that they have already become in- 
fected by poison. If the disease is not arrested here, the 
whole system may be involved. 

Milk Leg. — A swelling of one or both legs sometimes 
comes on after delivery. It is ushered in by acute pain 
and lines of redness accompany the swelling — the ves- 
sels of the groin, under the knee, or in the leg, will often 
feel like cords. This is due to an inflammation involv- 
ing the veins. Sometimes blood-clots form in the veins, 
which may be dislodged and carried to the heart and 
lungs, when they are the source of the gravest danger. 
Sometimes abscesses form in the leg. The great danger 
of clots being carried in the blood-current makes absolute 
quiet imperative. The patient should lie flat on her 



174 OBSTETRIC NURSING. 

back, and the limb be elevated on pillows or on an in- 
clined plane such as the fracture-box used in certain 
fractures of the lower extremity. 

The application of some soothing ointment, as iodin 
and belladonna ointment in equal parts, over the cord- 
like veins, a hot flaxseed poultice being kept over the 
ointment, will help to relieve pain and diminish inflam- 
mation. The whole limb should be kept warm by a 
wrapping of cotton-batting. The limb is most comfort- 
able when slightly bent at the knee-joint. Should the 
weight of the bed-clothing cause pain, a cradle may be 
made of barrel hoops for lifting them off the limb. The 
cradle is also very useful in cases of peritonitis when the 
same difficulty exists. 

Bed-sores. — Lying-in women should not be subject to 
bed-sores, but should some complication occur, as in 
some form of blood-poisoning, or should some other 
disease attack the patient during this time, necessitating 
long lying, special care is necessary to prevent bed-sores. 
The parts of the body subjected to most pressure should 
be kept thoroughly dry and rubbed with alcohol and 
alum (a saturated solution) once or twice daily. A little 
cosmolin may then be rubbed into the skin, or some dry- 
ing powder, as zinc or starch, may be used. When a 
sore occurs it must be dressed, according to the phy- 
sician's order, with zinc ointment or cosmolin. All 
pressure should be kept off it, if possible, by the 
adjustment of pads and pillows or a rubber-ring 
cushion. 



MANAGEMENT OF THE LYING-IN. 175 

Puerperal Mania is a form of mental trouble which 
may affect lying-in patients, particularly when they are 
exhausted from any cause, whether it be mental worry 
or physical ill-health. ; In true mania the patient may 
be violent and very difficult to control. In the melan- 
cholic type of this trouble she is exceedingly depressed, 
distrusts her best friends, and cannot be roused to take 
an interest in her surroundings. 

As soon as it is noticed that the patient's mind is not 
well balanced, the baby should be removed from the room, 
only being brought to the mother when asked for. The 
nurse should then keep a close watch over it, as one of 
the chief symptoms of this trouble is a strong aversion 
to the baby and desire to destroy it. 

It should never be forgotten that an insane patient 
should not be left alone for a moment. The insane are 
very cunning, and though apparently asleep may be but 
watching their opportunity to indulge in some mad 
freak, as jumping out of the window, dashing down the 
stairway and out of doors, etc., The windows, there- 
fore, should be in some way protected. A nail or screw 
may be driven into the window-casing so as to prevent 
the raising of the sash, except so far as ventilation re- 
quires. The door had best be kept locked, the nurse 
keeping the key. 

The treatment will consist mainly in keeping up the 
nourishment and in kind, gentle tactful management. 
The patient should be made to interest herself in outside 
things, by the judicious turn given to the conversation 



176 OBSTETRIC NURSING. 

by the nurse, by engagement in some kind of fancy-work 
or in games which will help to divert the mind. 

She should not be crossed, neither should she be de- 
ceived. The nurse should so marriage her as to inspire a 
thorough confidence and liking toward her on the part 
of the patient. If she has not these, she had best give 
up the case, as she will not be able to help the patient. 

Should the patient absolutely refuse to eat, the physi- 
cian may direct the nurse to introduce the food into the 
stomach by means of a rubber tube passed through the 
nostril and down the esophagus, or gullet. Care should 
be taken to do no injury in the introduction of this tube, 
which should be well greased with cosmolin and made to 
follow closely the direction of the passage it is made to 
enter. A funnel is then connected with the outer ex- 
tremity, through which the milk or broth, etc., may be 
poured into the stomach. 

Should the patient be exceedingly restless, and dis- 
posed to jump out of bed, to her own detriment, she 
may be fastened into the bed by means of a sheet, dou- 
dled lengthwise, placed over the middle portion of the 
body from the arm-pits to below the knees and carried 
under the bed, to be fastened either beneath the bed or 
to one side of it. The feet may be bound together loosely 
at the ankles by a piece of roller bandage and fastened 
to the footboard of the bed. The hands may be band- 
aged (being placed the one on top of the other) by 
means of a roller bandage, though this is not necessary 
except when they are used to do herself injury. When 



MANAGEMENT OF THE LYING-IN. 177 

patients are so violent as to need such restriction, how- 
ever, it is better to have them removed to some institu- 
tion for the insane as soon as possible, where there is 
better provision made for their management. The use 
of sedative remedies by the physician will generally pre- 
vent the necessity for resorting to such extreme measures 
for confining the patient in ordinary cases. 

Medicines should, of course, never be left in the 
patient's room, even when the nurse is there, unless un- 
der lock and key. The duration of this malady varies 
from weeks to months, in some cases becoming chronic. 
Convalescence is generally very gradual. Patients may 
have long periods of lucid thought, and seem ap- 
parently well, only to unexpectedly return to their 
vagaries; so that the nurse should never relax her 
quiet vigilance while in charge of the case. 

The First Sitting-up. — The old time-honored belief 
that a woman should sit up on the ninth day is subject 
to many exceptions, which should be understood by the 
nurse as well as the physician. The true gage is the prog- 
ress of involution. This may be determined by the 
height of the uterus (which ought to sink behind the 
pubic bone before the patient is allowed to sit up) and 
by the character of the discharges. So long as there is 
any blood in the discharges the patient should not sit up, 
for this is an indication that involution, or the shrinking 
of the womb, is not going on properly. This condition 
is known as u sub-involution ," and if neglected may lead 
to chronic disease of the womb. The use of the recum- 
12 



178 OBSTETRIC NURSING. 

bent or semi-recumbent posture, frequent hot injections 
given by the nurse, or remedies administered by the phy- 
sician, may be necessary to overcome it. Let the pa- 
tient understand the wisdom of her confinement to bed 
under such circumstances, and she will generally yield 
gracefully to the necessity. The first sitting-up should 
be in bed, the patient's back being supported by a bed- 
rest. Should no bed-rest be found in the house, a chair 
turned upside down, with its back toward the patient, 
over which a pillow is placed, offers a very good sub- 
stitute. 

After sitting up in bed for a day or two, from a half- 
hour to an hour if there be no discharge, the patient may 
have her flannel wrapper and stockings and bedroom 
slippers put on, and be allowed to sit up in an easy chair. 
It must be remembered that this is the time when the 
patient will be most susceptible to cold, therefore every 
precaution must be taken to prevent her exposure to 
draughts. Should the patient seem to grow tired be- 
fore the half hour or hour is up, she should be put back 
in bed. The interval for sitting up may be gradually in- 
creased from day to day, until she is up the greater part 
of the day. No going up and down stairs should be per- 
mitted until the physician sanctions it, which is, in ordin- 
ary cases, about the fifth or sixth week, when one such 
journey a day is generally permitted. 

Order-Chart. — That there may be no misunderstand- 
ing between physician and nurse, the orders of the 
physician in every case should be immediately set down 



MANAGEMENT OF THE LYING-IN. 



179 



in writing when given, so that by constant reference to 
them the nurse may do her full duty by the patient. It 
is well, for this purpose, to have a piece of paper ruled so 
that at the right side there shall be two columns, one 
headed a. m., the other p. m. The stated hours for the 
adminstration of medicine or carrying out of treatment 
may then be placed opposite the special directions 
for each, and a pencil mark be drawn through the fig- 
ure representing the hour when the matter has been 
attended to. 

An order-chart, as used in the Woman's Hospital, is 
prepared as follows: — 



Orders for Treatment of Mrs. Richards, Oct. 10, i 



A. M. 



P. M. 




Full breakfast, dinner, and supper 

A teaspoonful of medicine (light or dark) 

Sponge bath 

Lunch of gruel or beef-tea 

Glass of milk at bedtime 

To sit up half an hour with bed rest 



12, 6 

12.30, 6.30 

3 
8 



Nurse's Name 



A fresh chart should be prepared for each day's work. 
In ordinary cases, which run an uneventful course, these 
boards, with the hours crossed off, serve the purpose of 
a report as well. 



CHAPTER XIV. 

CARE OF THE NEW-BORN INFANT. 

The mother being made comfortable after her delivery 
the nurse should turn her attention to the infant. 

First Toilet. — Everything needed for the baby's first 
toilet should be collected and placed conveniently at 
hand, near the register, stove, or open fireplace. 

The nurse should put on a flannel apron or pin a crib- 
blanket or flannel petticoat over her lap. The best 
bath-apron is one consisting of two pieces of flannel 
fastened to the same waistband. The lower piece is the 
one on which the baby lies ; the upper serves as a cover- 
ing. A pitcher of warm water and one of cold must be 
provided, the baby's bath-tub being placed near them, 
the baby-basket, suit of aired clothing, and jar of ren- 
dered lard or oil within reach . The nurse should pick the 
baby up with its wraps and place it in her lap as she 
seats herself on a low chair or stool near the fireplace. 

The baby will be found to be covered over portions of 
its body by a white, greasy, substance, called "vernix 
caseosa, " or " cheesy varnish. ' ' This substance is found 
in greatest quanity on portions of the body subjected to 
friction while in the womb, hence it serves to protect the 
child's skin. 

180 



CARE OF THE NEW-BORN INFANT. l8l 

Some kind of grease is needed for its removal. Ren- 
dered lard and oil are the best. Cosmolin is not so good, 
as it is stiff er than the other two — not so soluble a fat. 
Lanolin is good. All this cheesy substance must come 
away with the first washing, as, if left, it irritates the 
skin and produces sores. The most difficult parts of the 
body to cleanse are the folds or creases. The nurse 
should take a piece of lard about the size of a walnut, 
rub it over the palms of both her hands, and then, taking 
the child's head between her hands, rub the grease thor- 
oughly in, giving especial attention to the ears. A 
second piece of lard, of the same size, will be needed for 
the neck, shoulders, arms, chest, and back; a third piece 
for the groin, external generative organs, and lower 
limbs. The creases and folds about the generative or- 
gans, especially of a girl baby, need very careful cleans- 
ing. When the baby has been completely covered, the 
nurse should take the corner of a dry sheet and rub off 
the grease. Many physicians prefer not having the baby 
bathed after this greasing. It may then be dressed and 
laid in its crib. 

Should the bath be preferred, the nurse should wrap 
the baby up in her flannel apron, draw the bath-tub to- 
ward her, and prepare the bath, filling the bath-tub 
about one-third full of warm water at a temperature of 
ioo° F., tested by the thermometer. A wall-thermom- 
eter, costing fifteen cents, may be obtained at any drug- 
store for the purpose. The baby is then placed in the 
tub, its entire body, excepting its head, being immersed 



1 82 OBSTETRIC NURSING. 

for a moment or two beneath the water. The nurse 
should keep the baby from slipping from her grasp by 
allowing its head to rest against her left wrist and hand, 
while the fingers of the same hand obtain a secure grasp 
under the child's left arm-pit. After the dip, the child 
is lifted out on to the nurse's lap again, where a soft, 
warm towel should have been spread for its reception. 
In this it should be wrapped and thoroughly dried. 
Great care must be taken to see that the arm-pits, groins 
and other parts of the body where creases exist are en- 
tirely free from moisture. Many physicians prefer that 
the child should not be put in the tub until the cord 
drops, a daily sponge bath being given until this occurs. 
The baby should always be thoroughly washed with 
simple warm water over the parts of the body soiled 
every time the napkin needs to be changed. Soap does 
not need to be used. Its frequent use would irritate the 
skin, and the parts can be perfectly cleansed without it. 

The use of powder in the folds and creases of the body 
is not essential. The main object is to keep rubbing 
surfaces dry, and should the nurse properly attend to 
this duty after the bath this, with the use of flannel next 
the baby's skin, ought to be sufficient to effect the pur- 
pose. Should a powder be desired, some very fine, un- 
irritating powder, such as plain talcum, might be used. 
Many of the scented powders contain substances which 
are irritating to the skin. 

Dressing the Cord. — After the baby has been dried, 
the stump of the cord or navel-string should be attended 



CARE OF THE NEW-BORN INFANT. 1 83 

to. Slit up a square of soft sterilized linen or gauze to 
its center. Put this around the cord, which is slipped 
through the slit (the slit looks upward toward the child's 
head), fold over the ends, and turn the whole upon the 
left side. Apply a bandage of sterile gauze to hold 
this dressing in place. Some physicians will direct that 
no dressing be placed around the cord. In fact, some- 
times there is no ligature placed around it, but it is 
simply well stripped of the blood and jelly-like sub- 
stance which help compose it, and thus allowed 
to dry. 

The placing of the cord with its dressing on the left 
side of the child's body is to avoid pressure upon the 
liver, which is larger than any other organ in the infant's 
body at birth, so large, in fact, as to extend quite down 
to the navel. The abdoijiinal bandage is put on over 
the bandage of sterile gauze. 

A drying powder, consisting of one part salicylic acid 
and five parts starch, is an antiseptic application 
thought by some to hasten the drying of the cord. 
Boric acid is sometimes used in the same way. 

The sterile dressing should be renewed daily. The 
abdomen around the navel being carefully washed with 
a boric acid solution each time. A cord kept dry by 
the frequent change of dressings will have no odor 
about it, and will drop, on an average, by the fifth day. 
The base from which the cord dropped may continue 
moist for a few days, and is best dressed by placing a 
small compress of antiseptic linen or gauze over it. 



184 OBSTETRIC NURSING. 

To prevent this from sticking, a little boric acid powder 
may be dusted over the moist surface. The navel- 
dressing is kept in place by the application of the 
flannel binder, which should be carefully adjusted, so as 
not to compress the abdomen too tightly. After the 
bandage is fastened, the nurse's hand, used flatwise, 
should be easily slipped in between the bandage and the 
baby's skin. Should safety-pins be used in fastening 
the bandage, they should be placed in front and not 
at the back, or they may cause the baby discomfort in 
lying. The bandage fastened by the tapes, which is 
simply wound around the body, is safer on this 
account. 

Great importance should be given to the proper care 
of the navel, as it offers an open surface on the child's 
body through which poisonous matter may be taken 
into the blood, causing " infantile sepsis," or the blood- 
poisoning of infants. 

Meconium. — Before the dressing of the cord, a napkin 
should have been laid beneath the hips of the infant, as 
there is very apt to be a free discharge of a dark, 
greenish matter from the bowels shortly after the birth. 
This is known as ' ' meconium. ' ' It should always come 
away within the first twenty-four hours after birth, and 
may continue to come at intervals for three or four days. 
When it does not come away freely the baby may suffer 
considerable pain. A soap suppository or a small injec- 
tion of warm water will bring about relief, causing an 
evacution of the bowels. 



CARE OF THE NEW-BORN INFANT. 185 

This substance is very difficult to wash out of napkins, 
hence it is a good plan to have a soft piece of old muslin 
placed inside the napkin to catch the discharge. This 
may be burned when removed. 

Cleansing. — The baby should be washed every time 
the napkin needs to be changed, even if it is only wet. 
Warm water should be used. A napkin should never be 
used twice without washing. The habit of hanging up a 
napkin wet with urine, allowing it to dry, and using it 
again, is not only filthy, but unsafe, as it renders the nap- 
kin irritating to the skin and a source of possible septic 
infection. For the same reason a napkin should be 
changed as soon as it is wet or soiled. Though the work 
may be irksome, a nurse should not weary of it ; for it is 
only by eternal vigilance that the child can be kept in 
good condition. 

Clothing. — After the application of the binder and 
napkin, the baby's under-vest, or little, long-sleeved, 
high-necked flannel shirt, should be put on. This 
should be fastened in front by safty-pins, or small, flat 
buttons or tapes. 

If the shirt is too large, folds should be made at the 
sides to make it fit better ; never in the back, because of 
the ridge this would produce under the surface upon 
which the baby lies. 

The socks come next, and then the flannel slip, con- 
stituting the only other garment the baby needs. The 
petticoat with slip, or Gertrude suit, may be used in- 
stead, if desired. 



1 86 OBSTETRIC NURSING. 

Eyes and Mouth. — The eyes and mouth should each 
be washed out with a separate soft piece of linen dipped 
in warm water. 

The Baby's Hair, if it has any, may be brushed with 
a soft baby-brush. No comb should be used, as the 
scalp is too tender. 

After care. — The baby should then be placed in its 
crib, on its right side, and warmly covered. The weaker 
the baby is, the warmer it will need to be kept. Stone 
jars, when filled with hot water, are nice for this pur- 
pose placed around the child, but care should be ex- 
ercised not to let these bottles be placed so near as to 
cause a burn. 

In another chapter we will consider the care of pre- 
mature infants. 

The weighing of the baby devolves often upon the 
nurse. A steelyard being provided, the nurse may 
place the nude child in a napkin, tied or pinned securely 
at the corners. This may be swung on to the hook 
of the steelyard as it is held up. The pointer will then 
indicate the number of pounds weight. The average 
weight of a new-born baby is 3250 grams (about seven 
pounds) . 

In the Woman's Hospital the ordinary grocer's pan- 
scales are used, the weights being represented in grams. 
The daily weight is taken and recorded on a card 
which hangs by a ribbon or string to the baby's crib, so that 
its daily condition may be carefully watched. For a 
comparison of the approximate weights in the metric 



CARE OF THE NEW-BORN INFANT. 187 

and avoirdupois scales, I append the following table of 
equivalents: — 

Relation of Avoirdupois to Metric Weights. 

Avoirdupois n-,™* Avoirdupois r»—„- 

Pounds. Grams. Pounds . Grams. 

1 453-592 6 2721.55 

2 907.18 7 3 I 75- I 4 

3 ; 1360.78 8 3628.74 

4 1814.37 9 4082.33 

5 2267.96 10 4535-92 

For the first three or four days a baby will lose weight 
as it does not take in enough nourishment to make up 
for the loss it sustains by the newly acquired activity 
of bowels, bladder, and skin. At the end of the first 
week the baby should weigh about what it did at the 
birth. After that it should gain on an average, thirty 
grams a day (about one ounce) for the first two months 
of its life. 

A Sponge Bath is sometimes given the baby at the 
close of the day, when its clothing is changed for the 
night ; but this is not necessary, if it has been properly 
attended to when the napkins have been changed. The 
fresh clothing at night is always essential. 

The Baby's Crib should have no rockers. All un- 
necessary swinging, rocking, and jolting of babies only 
serves to make them nervous and more troublesome to 
take care of. A convenient and inexpensive crib and 
bath-tub combined, especially for traveling, is describ- 
ed in one of the numbers of "Baby land' ' thus: 
The frame is made something like a cot-bed. Straight 



i88 



OBSTETRIC NURSING, 



pine sticks may be used. The legs, one inch and a 
half square by thirty inches long, are crossed and pivoted 
in the middle on a center bar. The side bars, one inch 
by two inches, and thirty-six inches long, are securely 
fastened to the top of the legs. Smaller bars join the 
legs near the bottom to stiffen the frame. A piece 
of heavy rubber cloth, one yard and a quarter long 




Fig. 48. — Home-made Bath-tub and Crib. 

and thirty inches wide has an inch-wide hem on each 
end for a casing, and is drawn up to eighteen or nine- 
teen inches with heavy braid (a leather strap would 
probably be better) . 

This makes the ends of the tub. Along the side bars 
of the frame are tacked with brass-headed tacks the 
sides of the cloth, the braid (or rubber straps) being 
securely fastened to the ends. A small plait in the cloth 
at each corner, about an inch from the end, gives a fuller 
shape to hold the water (when it is in use as a bath- 



CARE OF THE NEW-BORN INFANT. 189 

tub). The tub (or crib), when not in use, can be folded 
and set away out of sight, or it may be carried in the 
bottom of a large traveling-trunk when on a journey. 
The frame may be made of walnut or cherry, with 
turned legs, etc., if so desired. A pillow put in the tub 
makes a comfortable and portable crib for the baby. 

Children should never sleep in the same bed with 
their mothers. It is unsafe because there is danger of 
their being overlaid, and it is unhealthful because of the 
discharges, breath, etc., of the mother. 

Tubs for Babies. — Many varieties of tubs are made 
for babies, of tin or agate-ware, or porcelain. A tin 
foot-tub, unpainted, serves a good purpose while the 
child is small. These may be placed upon a bath-stand 
or low chair to prevent the necessity of too much 
stooping on the part of the nurse while bathing the baby. 

Training of a baby. — A baby may be trained to be 
contented and happy as it lies in its crib. If from its 
earliest days it is taken up simply to be fed, and to re- 
ceive the necessary attentions for keeping it clean and 
comfortable, it will not become the little tyrant a child 
develops into when foolishly spoiled by its mother. 

Feeding of Infants. — Babies should be fed but once 
in two hours during the day, and every three hours during 
the night, unless premature, when they take less, and 
should be fed every hour. An interval is necessary be- 
tween the feedings in order that the stomach may rest 
and be prepared properly to carry on its work of diges- 
tion. Hence the habit some mothers have of letting 



190 OBSTETRIC NURSING. 

babies nurse whenever they cry simply serves to produce 
indigestion, as well as to spoil the child. 1 

For its first nursing the baby may be put to the breast 
an hour or two after labor, if the mother is sufficiently 
rested. The nipples should, before each nursing, be 
carefully washed off with a solution of boric acid. The 
early secretion of the breasts, known as "colostrom, " 
helps to rid the baby's bowels of their dark, tarry con- 
tents, as it is laxative. It is important that the breasts' 
should be used alternately in feeding the infant, as this 
allows a longer time to elapse for the accumulation of 
milk. For the first day or two the baby needs compar- 
atively little food. Should it seem to be hungry, 
however and the mother unable to satisfy it, a teaspoon- 
ful or two of warm water or diluted peptonized cow's 
milk, prepared according to the suggestions to be given 
Jater, may be administered at regular intervals. 

Before and after each feeding, the baby's mouth 
should be carefully washed out with a piece of soft linen 
dipped in warm water or a saturated solution of boric 
acid. This is to prevent the particles of milk remaining 
in the mouth from producing soreness by souring. 

Two or three times daily a baby should be gi\^en a tea- 
spoonful of cool water to drink, as babies suffer from 
thirst just as their elders do. The water assists, also, 
in keeping the bowels from becoming constipated. The 
water should be boiled and kept in an air-tight flask. 

• *It has been observed that when the periods between nursing were short 
the milk was more condensed, a fact which throws light on the dyspeptic 
phenomena occurring in babies who are fed too often. — Rotch. 



CARE OF THE NEW-BORN INFANT. 191 

Insufficient Milk. — Should the mother not have suf- 
ficient milk for her baby, it may have the bottle every 
other time, the additional food being selected with refer- 
ence to the child's age and powers of digestion. 

The Wet-nurse. — When a mother has no milk, the 
best substitute is a good wet-nurse. A wet-nurse 
should always be carefully examined by a physician, 
that her freedom from disease may be fully determined 
before she is employed. She should be between twenty 
or thirty years of age, and have good, not necessarily 
large, breasts, well-shaped nipples, and an abundant 
supply of milk. The condition of her own child should 
be considered, whether it be thriving or sickly, and es- 
pecially whether there be any evidence of special dis- 
ease. It is well, too, to try to get a woman who has 
had more than the one child, as a woman who has borne 
several children has, by experience, learned to under- 
stand and manage babies. 

Lactation. — The first milk that comes in the breast, 
and which appears in any quantity, about the eighth 
month of pregnancy, is called "fore-milk," or "colos- 
trum, ' ' from a word which means ' ' glue. ' ' It is turbid, 
yellowish, gluey, alkaline in reaction, and sours easily. 
It differs from true milk in having a higher specific 
gravity or weight ; it also contains more salts and more 
albumin, and is more difficult to digest. It is laxa- 
tive in its effect upon the baby's bowels. Physicians 
not infrequently examine a specimen of this secretion 
under the microscope, to learn what the prospect is as 



192 OBSTETRIC NURSING. 

to the mother's nursing the child. If, in the last two 
months of pregnancy, the colostrum is scanty, and un- 
der the microscope there are but few oil globules, the 
patient will probably have poor milk and scant in quan- 
tity. If the colostrum is abundant but thin, like gum- 
water, not gluey and without yellowish streaks, it is 
probable that the milk will be watery and not nourish- 
ing. It may be either scanty or abundant. If the 
colostrum be plentiful, with yellowish streaks and full of 
milk globules, the milk will be abundant and good in 
quality. The secretion of colostrum may continue 
from six to eight days. If it continues longer, it is a 
great disadvantage, and the mother may have to give 
up nursing because of the child's inability to digest the 
nourishment thus afforded. 

Human milk should have a specific gravity of 1020- 
1034. It is slightly alkaline in reaction; that is, it will 
turn red litmus-paper blue, and it contains the follow- 
ing ingredients : — 

Water, 87-88 

Total solids, 13— 12 

Fat 3-4 

Albuminoids, 1-2 

Sugar, 7.0 

Ash, 0.2 

—Rotch} 

It differs from cow's milk in having a higher specific 
gravity, more solids, less water,and one-fifth the 

1 According to the analyses of Dr. H. Leffmann, the percentage of fat 
rarely reached 4, ranging between 2.5 and 3, as a rule, while the albumin- 
oids were usually a fraction over 1 per cent. 






CARE OF THE NEW-BORN INFANT. 193 

amount of albuminoids. The milk retained longest in 
the breast — the first milk drawn by the baby at each 
nursing — is the thinnest ; the last, the richest. When, 
therefore, a baby seems to suffer from indigestion because 
of its mother's milk being too rich for it, it should take 
the first secretion from each breast at each nursing in- 
stead of drawing all the milk from one breast. One or 
two teaspoonfuls of water given the baby before each 
nursing have the same object. Should it, on the con- 
trary, not seem to thrive because of the food not be- 
ing sufficiently rich, the thin milk should be pumped 
or drawn out of each breast by the nurse or mother be- 
fore the baby is allowed to draw. The two breasts 
are estimated to contain about two ounces of milk 
at one time. 1 

The question of how to increase the secretion of milk is 
a v r ery important one. The best way is by a judicious 
regulation of the mother's or wet-nurse's diet. There 
are no medicines which are entirely satisfactory for the 
purpose of stimulating the secretions. Therefore a 
nurse can do more than a doctor in this line by careful 
feeding of her patient. A mixed diet is the best for 
making milk. Beer and all kinds of liquors, as porter, 
etc., do more to fatten the mother or nurse than to make 
milk; therefore they are to be avoided. In weakly 
women with poor appetites the malt and bitter tonics 
are sometimes of advantage in stimulating the appetite 

1 The use of from 1 to 5 drops of cod-liver oil, according to the age of 
the child, given three times daily, has been found to be a valuable supple- 
ment to the food when a mother's milk lacks richness. — Dr.A.E. Broomall. 

13 



194 



OBSTETRIC NURSING. 



/ 



s 




and thus promoting a greater secretion of milk. The 
special diet for a nursing woman is laid down in another 
chapter. Good human milk should be three per cent. 
cream. 1 

To determine the character of milk — human or cow's 
milk — an instrument known as the lactometer, or milk- 
tester, may be used, aided by the microscope. 

The Lactometer consists of a cylin- 
drical glass vessel, or beaker, which 
should contain the milk to be tested, 
and a specific gravity glass, which is to 
be floated in the liquid. This glass is 
graduated and marked at certain points 
with letters and figures. Thus, W., P., 
and P. The W. stands for "water," 
P. for "pure," and F. for "fat." Be- 
tween the W. and P., at different points, 
are the fractions, 1/4, 1/2, 3/4. Should 
the weighted glass sink in the liquid so 
that the surface of the liquid reached 
the mark W., the liquid tested would 
have the same specific gravity as water. 
Should the surface of the liquid reach 
the mark 1/4, if it is milk that is tested, it would 
be 1/4 milk and 3/4 water. If the mark 1/2 i's 
touched, it is 1/2 water and 1/2 milk. In this way 

1 As general rule, the amount of fat may be increased by increasing the 
amount of meat in the diet, and the amount of albumin decreased by mod- 
erate exercise.. Too little fat and too much casein make poor milk. 

— Rotch. 



Fig. 49. — Lactom- 
eter. 



CARE OF THE NEW-BORN INFANT. 195 

the adulteration of the milk with water is detected. 
Should the level of the liquid stand at P., we would have 
pure milk. Pure cream would raise the weighted glass 
so that the level of the liquid would stand at F. An or- 
dinary urinometer may be used to obtain the specific 
gravity of milk in a similar way. Dr. Louis Starr sug- 
gests a good way to discover the proportion of cream 
in any given sample of milk: A narrow piece of pa- 
per four inches long, is divided in its upper half inch 
by cross-markings into twelve equal parts. This paper 
is then pasted on the beaker of the lactometer with 
the marked portion uppermost, the lower edge touch- 
ing the bottom of the beaker. Enough milk is then 
poured in to come just to the top of the paper, and 
the whole set aside for twenty-four hours. The 
cream rises and appears as a yellow layer at the top. 
This layer should have the depth of ten or twelve spaces, 
as marked on the paper. There is an inexpensive instru- 
ment known as the creamometer which serves the same 
purpose in determining the amount of cream in milk. 
On examination under the microscope, if there are 
but few oil globules in a specimen of milk, and if these 
oil globules be small, the milk is poor. On the other 
hand, if the oil globules in milk are too large, this 
becomes a cause for its indigestibility. 

Should menstruation begin with a nursing mother, the 
milk may be so affected as to disagree with the child. 
Ordinarily, the menstrual flow does not recur until the 
eighth month after delivery. The appearance of the flow 



196 OBSTETRIC NURSING. 

need not lead to a cessation of nursing, unless the milk 
should seem to disagree with the child. The character 
and quantity of the milk is impaired by deep or violent 
emotions; thus, anxiety, fear, anger, etc., will greatly 
detract from a woman's ability to be a good wet-nurse. 
Pregnancy always deteriorates the character of milk 
and is an indication for weaning a nursing child. 

Hand-feeding. When the mother's milk utterly 
fails and a wet-nurse can not be had, hand-feeding be- 
comes necessary. For this purpose " modified cow's 
milk" may be used. 

Cow's Milk has a specific gravity of 1029. The milk 
obtained from stall-fed cows gives an acid reaction; 
that from pasture-fed cows a less acid reaction. Could 
the latter be obtained directly from the cow, its reaction 
would be slightly alakaline, as with human milk. An 
analysis of the same quantity of woman's milk and 
cow's milk is reported as yielding the following results: 

Woman's Milk. Cow's Milk. 

Water 87.88 parts. 86.87 P arts - 

Total solids 12.13 parts. I 3- 1 4 parts. 

Fat 4.00 parts. 4.00 partsf 

Albuminoids 1.00 parts. 4.00 parts. 

Milk-sugar 7.00 parts. 4.5 parts. 

Ash 0.2 parts. 0.7 parts. 

Bacteria not present. present. 

The woman's milk for this analysis was obtained di- 
rectly from the breast. The cow's milk was, as it is 
ordinarily obtained in cities, about twenty-four hours 
old. 



CARE OF THE NEW-BORN INFANT. 197 

By an examination of this analysis, it will be seen 
that the proportion of coagulable substances of cow's 
milk is much greater than in human milk. This is 
where the difficulty in its digestion lies. Casein of 
human milk coagulates in light curds; in cow's milk in 
firm, hard curds. 

Quality of Food. — The kind of food required by dif- 
ferent babies will vary with their constitutions. As a 
rule, a mother's milk is the best food for her child, and 
makes a good gage to start from in the preparation of 
an artificial food to take its place or act as a supplement 
when there is an insufficient supply. If, therefore, a 
careful analysis is made of a mother's milk and a mix- 
ture prepared which shall, so far as possible, contain the 
same constituents in the same proportion, w r e may hope 
that the baby will thrive on it. A steady increase in the 
baby's weight will be the best index by which we can 
judge of the nutritive qualities of the food it is 
taking. 

Increase in Weight. — For the first four or five months 
of its life a child should gain on an average twenty to 
thirty grams (about one ounce) daily. For the remain- 
der of the first year of life, a daily gain of from ten to 
fifteen grams will mark satisfactory progress. 

In the comparatively few cases in which a mother's 
milk does not appear to have proper nutritive or diges- 
tive properties, it should be examined to discover in 
what direction the deficiency lies, and the artificial food 
should be prepared so as to supply the lack. The 



198 OBSTETRIC NURSING. 

nutritive constituents of milk are the albuminoids, fat, 
and milk-sugar. 

Modified Cow's Milk. — Cow's milk contains about 
four times the quantity of albuminoids found in human 
milk, so that it requires to be diluted with four times 
as much water to represent the same percentage of albu- 
minoids. Since the amount of fat in human and cow's 
milk is about equal, this dilution would greatly decrease 
the percentage of fat. Also, since cow's milk contains 
a much smaller quantity of sugar of milk than is found 
in human milk, the same dilution would be greatly defi- 
cient in sugar. 

In preparing a mixture from cow's milk, there- 
fore, that will correctly represent human milk, fat, 
in the form of cream, and sugar of milk must be 
added. 

Laboratories for the preparation of modified cow's 
milk according to the requirements of individual cases 
have been established in several of the large cities. 
Physicians are requested to send prescriptions giving 
the proportions of the different constituents of milk re- 
quired for their patients, and from these the pre- 
parations are made, sterilized, and served daily to the 
patient. The prescription can be modified whenever 
required to meet conditions as they arise in the course of 
management. 

Cream varies very much in richness; hence it is de- 
sirable to know what percentage of fat is represented 
by the cream used in compounding a mixture. A 



CARE OF THE NEW-BORN INFANT. 199 

chemical analysis of the cream is necessary for accuracy 
of result in such determination. It has been suggested 
that to prevent too much variation in the percentage of 
fat, the cream should be obtained of the same person 
from milk that has been allowed to stand each day 
for the same length of time and in the same tempera- 
ture. 

Rotch's Formula for Modified Cow's Milk. — A mix- 
ture made up according to the following rule probably 
most nearly resembles the average human milk.' To 
make one pint of the mixture for use in twenty-four 
hours, take milk and cream (twenty per cent.) as soon 
as it comes in the morning, and mix as follows: 

Milk f § ij 

Cream f § iij 

Water fgx 

Milk sugar 3 vif . 

Put in a flask in the steamer and steam for twenty 
minutes ; then remove the flask from the steamer, and 
when still slightly warm add lime water f §j. Place on 
ice, and give the proper amount at the proper feeding 
time, warming the quantity of the mixture used in a 
water-bath before giving it to the baby. 

The object in steaming the mixture is to sterilize it, 
for human milk is sterile, and for that reason more 
digestible than cow's milk — which, although sterile 
while in the udder, becomes contaminated as it is placed 
in vessels and transferred from place to place. It is 



200 OBSTETRIC NURSING. 

believed by some that this steaming or boiling of milk 
has a tendency to decrease its digestibility. The dan- 
ger from this source, however, is probably much less 
than that which would arise from the presence of germs 
in the milk, such as have been shown to exist. "Frac- 
tional sterilization," the heating of milk in a water- 
bath several times in succession up to a more moderate 
degree of heat than that required for complete steriliza- 
tion (167 F.), is said not to have the same effect in 
decreasing digestibility of milk. 

Pasteurization of Milk. — The process which is known 
as Pasteurization (after the French scientist, Pas- 
teur) is a modification of sterilization, the tempera- 
ture of the milk being brought up only to 167 Fahren- 
heit instead of to 212 , which is done in sterilizing. 
It is claimed that this process destroys the germs 
sufficiently for all practical purposes. It does not, 
however, with certainty kill the germs, hence a method 
has been suggested by which the milk can be brought 
to a higher degree of heat, and yet not lose its digesti- 
bility. 

The bottles of the sterilizer are filled and the appara- 
tus made ready in the usual way, but the hood is left 
off and the lid set ajar, while the heating is continued 
for forty- five minutes over a brisk fire. The tempera- 
ture of the milk is thus brought up to about 190 . 
It has been found that milk thus prepared and kept 
in well-corked bottles will keep sweet for twenty-four 
hours. 



CARE OF THE NEW-BORN INFANT. 201 

Lime-water is added to make the mixture alkaline, 
all human milk being slightly alkaline. It should 
not be placed in the flask before boiling or steaming, 
because experimentation has shown that the lime 
undergoes some change in the process of boiling which 
causes a discoloration of the milk and the deposit of a 
sediment: Experiment has shown that w T ater is the 
most efficient diluent to be employed in making these 
mixtures, as it gives a much finer curd with acids, when 
so used, than can be obtained by an admixture with 
barley-w T ater or any of the prepared foods. 

Having thus determined by analysis the quality 
of the food required for an infant, the quantity must 
be determined and also the frequency of feeding. 

As to Quantity, the observations made by Dr. Ssnit- 
kin, of St. Petersburg, have led to the formulation of a 
rule by which one one-hundredth of the baby's weight 
should be taken as the figure with w 7 hich to begin the 
computation, and to this should be added one gram 
for each day of life. 

A table prepared by Dr. Rotch, of Boston, has ar- 
ranged in very convenient form the quantity and inter- 
vals of feeding for the first year of a child's life: — 



202 



OBSTETRIC NURSING. 

General Rules for Feeding. — (Rotch.) 



Age. 



Intervals 

of 
feeding. 



Number 
of feedings 

in 
24 hours. 



Average 

amount at 

each feeding. 



Average 
amount in 
24 hours. 



1st week. 


2 hours. 


10 


1 1 ounce. 


10 ounces. 


1-6 weeks. 


2 J hours. 

1 


8 


1 J- 2 ounces. 


12-16 ounces. 



6-12 weeks and 

possibly 

to 6th month. 



3 hours. 



6 3-4 ounces. 18-24 ounces. 



At 6 months. 


3 hours. 


6 


6 ounces. 


36 ounces. 


At 10 months. 


3 hours. 


5 


8 ounces. 


40 ounces. 



Another table arranged by Dr. Rotch shows the 

amount required at each feeding, according to the 

weight of the child. 

Determination of Amount of Food by Weight in Cases of 
Special Difficulty. 



Initial 
weight. 



Each feeding. 



Early days. 



At 15 days. 



At 30 days. 



3000 
grams. 



30 grams. 
(About 1 ounce.) 



30+15=45 grams. 
(About 1 J ounces.) 



30 + 30 = 60 grams. 
(About 2 ounces.) 



45oo 43 grams, 

grams. (About ij ounces.) 



45 + 15 = 6 ° grams. 



45 + 30 = 75 grams. 



(About 2 ounces.) (About 2\ ounces.) 



6000 60 grams, 

grams. (About 2 ounces.) 



60+15 = 75 grams. | 60 + 30 = 90 grams. 
(About 2 J ounces.) (About 3 ounces.) 



CARE OF THE NEW-BORN INFANT. 203 

Stomach of Infant. — A new-born infant's stomach 
holds about i 1/2 ounces. The average daily quan- 
tity of food required for the first two to three months 
is 20 ounces; after three months, 23 ounces; after four 
months, 27 ounces; six to twelve months, 30 ounces. 
The child's appetite, however, if it be healthy, is a 
good gage. During the first month, 1 1/2 ounces 
of the prepared cow's milk may be given at each 
feeding, and 1 2 feedings given daily. 

Peptonized-food, diluted, has been employed with 
great success by some physicians where the digestive 
powers in early childhood seemed at fault. The follow- 
ing formula may be used for the purpose: 

Into a clean quart bottle put one measure, or five 
grains, of pancreatic extract (Fair child's), and one 
measure, or fifteen grains, of bicarbonate of soda, 
and a gill 1 of cold water; shake, then add a pint of 
fresh cold milk, and shake the mixture again. Place 
the bottle in water at about 1 io° or 1 15 , or just so hot 
that the whole hand can be held in it for a minute 
without discomfort. Keep the bottle there for 
twenty minutes. At the end of that time put the 
bottle on ice to check further digestion and to keep the 
milk from spoiling. 

If heat cannot be conveniently provided, after the 
ingredients have been throughly mixed and shaken 
the bottle may be placed on ice and allowed to stand 
for an hour before it is used. 

*A gill represents 4 ounces 



204 OBSTETRIC NURSING. 

It must be remembered that peptonized milk can- 
not be sterilized, as it then becomes unfit for food — 
the process of digestion being carried so far as to 
curdle the milk and render it extremely unpalatable. 
Sterilized or Pasteurized milk may, however, after it has 
cooled, be peptonized. 

If an additional aid to the digestion should be 
necessary, a little pepsin may be given to the child 
just before each feeding, or the pepsin, or any of the 
powdered preparations used to aid digestion that may 
be prescribed by the physician may be placed in the 
nursing bottle just as the child takes it. Pancreatic 
extract and soda, if used, will need to be given about 
an hour after the meal. 

Favorite Formulae for Modified Milk. — A preparation 
of modified milk which has been much used by Dr. 
Broomall is the following, in amount for a single feed- 
ing:— 

Cream i teaspoonf ul 

Milk 3 teaspoonfuls 

Lime-water 2 teaspoonfuls 

Boiled water 10 teaspoonfuls 

Milk sugar J teaspoonful. 

To make this up in quantity for sterlization the fol- 
lowing proportions are required : — 

Cream J ounce 

Milk '. 1 ounce 

Lime-water 1 ounce 

Water 17 J ounces 

Milk sugar 6 ounces. 






CARE OF THE NEW-BORN INFANT. 205 

Formulae in use in the Maternity of the Woman's 
Hospital. 

First week: fat i%, sugar 5%, proteids .75%. 

Cream (10%) gii 

Milk gii 

Boiled water gxv 

Lime-water gi 

Sugar of milk 5 vii 

Give f giss at each feeding. 

Second week: fat 2%, sugar 5%, proteids .75%. 

Cream (10%) giv 

Boiled water gxv 

Lime water gi 

Milk sugar 3 vii 

Give f g If at each feeding. 

Third week: fat 2j%, sugar 6%, proteids i%. 

Cream (10 %) g v 

Boiled water gxiv 

Lime water .. gi 

Sugar of milk 3 vii ss 

Give f gii to iii at each feeding. 

Simplified Formula for Modified Cow's Milk. — 

Take of "top milk" (the upper portion of good 
milk which has been allowed to stand in a suitable 
place six to eight hours) one part, and add to this two 
parts of water. This gives about the same propor- 
tion of cream and curd as in mothers' milk, but lacks 
sugar. Milk sugar (obtainable at any drug store) 
may be added to this in the proportion of one heaping 
teaspoonful to every four ounces of the mixture. If 



206 OBSTETRIC NURSING. 

cane sugar is used, a teaspoonful should be added 
to every six ounces. 1 

The Temperature of the Food should be 99 Fahr. 
It is a great mistake to make it too hot. The warm- 
ing of the child's food should be accomplished by set- 
ting the filled nursing bottle into a vessel of hot water. 
It may be heated quickly over a gas jet by setting 
the bottle into a tin mug filled with water and hold- 
ing it over the flame. Suggestions concerning the 
modification of food, when milk thus prepared does 
not agree with infants, will be given in another 
chapter. When the mother's supply of milk is scanty 
and the baby cries with hunger, occasional meals 
of the above preparations will be a great aid in its man- 
agement. 

Sterilization of Milk. — By sterilizing milk is meant 
the process of destroying any poisonous matter which 
may have found its way into it. Exposure to the atmo- 
sphere and admixture with particles of dust and dirt 
during its transportation, with want of care as to clean- 
liness of vessels, etc., in which the milk is kept, induce 
certain fermentative changes, which cause it to sour 
and to produce digestive disturbances. Sterilization de- 
stroys the germ of poisonous matter by subjecting the 
milk to a high degree of heat under pressure. Many 
forms of apparatus have been devised for this purpose. 
The accompanying cut represents one form. That 
shown in the cut consists of an oblong case of tin fitted 

1 For Dr. Rotch's formula see page 199. 



CARE OF THE NEW-BORN INFANT. 207 

with a tight cover. Into this a movable wire basket, 
holding ten bottles, is placed. The bottles are of flint 
glass, graduated, and fitted with rubber corks having a 
glass plug fitted into an opening in their centers. The 
rules for using the sterilizing apparatus are as follows : — 

1st. Cleanse the bottles throughly. 

2d. Fill each with the milk you wish to use, put in 
the rubber cork without the glass plug (this leaves a 
small opening in the rubber cork) ; set the bottle in the 
basket, then in the boiler ; fill the boiler with water al- 
most as high as the milk in the bottle ; boil about ten 
minutes, or, better, as Dr. Starr expresses it, 
"until the expansion that precedes boiling has taken 
place in the milk" ; then put the glass plugs tightly in 
each stopper and boil fifteen or twenty minutes more. 
Should the rubber corks incline to come out during 
the second boiling, put them in firmly. 

3d. Keep in a cool place till needed for use. 

4th. When to be used, place a bottle of the milk thus 
prepared in the tin mug which accompanies the appara- 
tus. Pour hot water into the mug until it is as high 
as the milk in the bottle. Heat the milk to the tem- 
perature desired for feeding (99 Fahr.) ; remove the 
rubber cork and put on rubber nipple, and feed. 

5th. Cleanse each bottle immediately after the milk in 
it is used. Do not keep milk in a bottle that has 
had some used out of it. 

6th. If the steaming process is preferred, place 
the basket, without the bottles, in the boiler, fill with 



208 



OBSTETRIC NURSING. 



water up to but not above the bottom of the basket, 
place the bottles in the basket, and proceed as before. 
Milk should be sterilized or Pasteurized as soon as 
possible after it has been served each morning. Each 
bottle, when emptied, should be thoroughly washed. 




Fig. 50. Sterilizer. (Dr. Louis Starr.)' 



If the whole contents of the bottle are not used after 
it is opened, the remainder must not be used for the 
child nor allowed to remain in the bottle. 

Milk sterilized in this way will keep for days with- 
out spoiling, as it is hermetically sealed and has been 
deprived of all unhealthy germs. Dr. Louis Starr 
makes the assertion that it will keep for eighteen days 
if the heating is continued for thirty minutes. 

1 "Hygiene of the Nursery." 



CARE OF THE NEW-BORN INFANT. 209 

Sterilized milk is useful when traveling, as it may 
be carried without any trouble, the difficulty of ob- 
taining fresh milk being thus overcome. Its use makes 
the management of babies during the heat of summer 
much easier. 

A word remains to be said concerning feeding- 
bottles and rubber nipples. 

The Nursing-Bottle should be of clear glass, with a 
rounded bottom, of a shape convenient to clean, so 
that no particles may cling about corners which can- 
not be reached, serving as a source of trouble after- 
ward. The graduated bottle is very convenient, as 
it enables the quantity of each of the materials used 
in the preparation of the feeding to be mixed directly in 
the bottle, instead of being first measured out in a 
graduate. 

Feeding-bottles with India-rubber tubes should never 
be used for the tubes are difficult to keep clean, and 
a drop or two of milk left behind will often be suffi- 
cient to turn the next supply sour, causing the infant 
much sickness and suffering. Nurses are prone, also, 
with these tubes, to place the baby in its crib with the 
bottle of milk by its side and the nipple in its mouth. 
The heat of the child's body tends to sour the milk, the 
liquid may run low, and the child suck in considerable 
air. The neck of the bottle should always be kept filled 
with the liquid while the child is nursing, hence the posi- 
tion of the bottle must be changed. A feeding-bottle 
fitted with a rubber nipple requires to be held in the 
14 



2IO 



OBSTETRIC NURSING. 



nurse's hand during the feeding, and is, on that account, 
to be preferred. There should always be two nursing 
bottles for each baby, one being kept under water or 
filled with a soda solution while the other is in use. 
Immediately after the meal the bottle should be cleaned, 




Fig. 51. — Graduated Nursing Bottle. (Dr . Louis Starr .) 

etc., Scalding water should be used, and then the 
bottle filled or placed beneath a solution of bicarbonate 
of sodium — ordinary baking soda — a teaspoonful to the 
pint, until it is again needed, when the soda solution 
should be emptied out and the bottle thoroughly rinsed 




CARE OF THE NEW-BORN INFANT. 211 

with cold water. Some nurses use salicylate of sodium 
for the cleansing solution in preference to the bicar- 
bonate. 

Rubber Nipples. — Tw t o nipples should be in use at the 
same time, being used alternately, and no nipple should 
be used longer than tw T o weeks. A soft rubber nipple of 
conical shape is the best, because it can be more readily 
cleaned. The black rubber is generally 
softer than the white, and is to be pre- 
ferred. The opening at the top of the 
nipple should not be too large, as that 
would permit the milk to flow through, 
whereas the suction produced by the 
child's mouth is necessary to the food £f G - 5 2 -— ^Y? BE * 

J Nipple. [Starr.) 

being taken in a natural manner. So 
soon as the meal is over, the nipple should be removed 
from the bottle, brushed with a stiff brush, wet with cold 
water on the outside, chen turned inside out and similarly 
brushed on its inner surface. It should then be put in 
cold water and allowed to stand until wanted. A 
nurse's sense of smell should be keen enough to enable her 
to detect the slightest sourness about a bottle or nipple. 

The baby should be fed slowly — taking often ten to 
twenty minutes for its meal. Sucking from an empty 
bottle should never be permitted. 

It is a bad plan to make the whole day's supply of 
food in the morning, unless the facilities for keeping it 
are such as to insure against its spoiling. When a 
sterilized preparation is used, it is desirable to have the 



212 OBSTETRIC NURSING. 

whole amount prepared at once in a number of small 
flasks, each containing the amount for one feeding. 

The sterilization of the quanity of milk to be used dur- 
ing the day may all, however, be accomplished at one 
time. 

Home-made Sterilizer. — In lieu of the regular steriliz- 
ing apparatus, milk may be similarly boiled in a water- 
bath formed by an ordinary boiler, the milk being con- 
tained in a glass fruit-jar with a screw lid. After com- 
ing to the boiling-point, or boiling about two minutes 
without the lid, the latter may be screwed on and the 
boiling continued. A better way is to put the jar in a 
colander placed over a steaming tea-kettle in place of 
the lid. The milk should be allowed to boil in the open 
jar for about two minutes ; the jar lid then being screwed 
down, it should steam for twenty-minutes. 

Fresh Air. — Besides good food and sufficient warmth, 
babies need an abundant supply of fresh air, hence the 
room should be kept pure and wholesome. 

In fine weather, after the first three or four_weeks, a 
baby should be carried out in the open air every day 
for a time. 

It is preferable to carry the child in the arms, rather 
than to place it in a baby-coach. It can thus be kept 
warmer, and any evidence of chilling will be sooner de- 
tected by the appearance of the baby's face. When it 
is not practicable to take the child out, the baby warmly 
wrapped may be carried about in a room, the windows 
of which have been raised, and free ventilation obtained. 



- CHAPTER XVI. 

CHARACTERISTICS OF INFANCY IN HEALTH AND DISEASE. 

A healthy baby, if born at full term, should weigh 
3250 grams, or about seven pounds. Its length should 
be, on an average, 50 cm., or twenty inches. 

Development. — The head and trunk of the child are 
developed out of proportion to the limbs, so that the 
navel is below the middle of the child's body. This 
greater development of the upper part of the body is due 
to the fact that in the womb this portion of the child's 
body receives the greater amount of nourishment. The 
subsequent growth consists largely in the development 
of the lower limbs. 

The skin of a new-born baby varies in color from a 
pink to a decided red. The redness is more marked in 
premature babies. From the third to the fourth day 
this redness dissappears, and the peculiar yellowish 
tinge, known as "baby jaundice," appears, as a result of 
the changes in the circulation . This is not true j aundice . 
This yellowish tinge of the skin should disappear by the 
end of the second w T eek. At the same time that the skin 
begins to change color, from the third to the fourth day, 
it begins to scale or peel off. This is most noticeable 
about the fifth day, and lasts about sixteen days. 

213 



214 OBSTETRIC NURSING. 

The baby's limbs should be plump and well-rounded. 
The abdomen is prominent, as compared with the chest. 

The shape of the head varies very much. At times it 
is perfectly rounded, again it will be elongated and oval- 
shaped. 

Pressure during labor, either from the walls of the pel- 
vis or as a result of the use of instruments, will cause at 
times considerable temporary distortion in the shape of 
the head. To allay swelling and prevent discoloration 
induced by bruising, fomentations may be used, either 
of simple hot water, or hot water containing a little fluid 
extract of hamamelis. Sometimes it is better to use cold 
applications, if the child is not too feeble. 

When there has been a good deal of pressure on the 
baby's head during the birth, the bones will sometimes 
override each other, and this will be shown by elevations 
or ridges upon the baby's head, which soon disappear 
when the head is no longer subjected to pressure. These 
ridges, which are converted into soft grooves on the 
removal of pressure, indicate the separation between the 
different bones of the head, and are called "sutures." 
The larger soft places are called "fontanelles." The 
largest is on top of the head just above the forehead. It 
is called the "anterior fontanelle," commonly known as 
' ' the opening of the head. " It is about large enough for 
the tips of two fingers to cover, when of normal size, and 
is kite-shaped. A much smaller three-cornered fon- 
tanelle is found at the back of the head, and two behind 
the ears. These very soon fill up with bone. 






FEATURES OF INFANCY IN HEALTH AND DISEASE. 215 

The large anterior opening does not close entirely 
until a child is about eighteen months of age. Should it 
remain open longer, it is a sign of constitutional weak- 
ness. In a healthy baby the surface of this fontanelle 
should be on a level with the surrounding bones of the 
skull. A slight puslation may be noticed in it, due to 
the pulsation of the blood-vessels in the brain. Should 
the fontanelle be much depressed at any time, it would 
indicate a low state of vitality. Care should be taken 
not to permit any undue pressure on this part of the 
baby's head, as the brain here lies very near the surface. 

The fashion some old monthly nurses have of trying 
to shape the head by the pressure of the hands is danger- 
ous, as the brain may be thus injured. As the head 
bones are soft, the child should not be allowed to lie too 
continuously on either side or on the back, as this will 
cause flattening of the part pressed upon. 

The first hair of the new-born baby, if it has any, is 
apt to fall out. The eyes of all new-born babies are of 
rather an indefinite color — a sort of blue. A change 
generally occurs when the child is about two months 
old. At this time also vision is nearly perfect. A new- 
born baby probably cannot do more than distinguish 
light from darkness. Hearing and the sense of smell 
develop rapidly in a child. Loud noises waken it as 
early as during the first week. By three months of age 
the child shows that it has a mind and is capable of ex- 
ercising thought. It grasps after objects and indicates 
by its expression and gestures its likes and dislikes. By 



2l6 OBSTETRIC NURSING. 

the age of eight or ten months it utters several syllables, 
and at the age of a year should be able to say "papa" 
and "mamma." By two years of age short sentences 
can be used. 

Weight of Baby. — For the first two days of a bab/'s 
life it loses weight, but by the third day it begins to gain, 
and by the end of the first week it should weigh what it 
did at birth. The average daily gain is 30 grams, about 
1 oz. The following facts concerning the early changes 
in weight are obtained from Gregory : — 

An infant born at full term weighs from 6 to 7 pounds, 
7 pounds being an average weight. For the first two or 
three days of life there is a loss of 4 ounces to 7 ounces, 
then a regular gain, so that by the eighth to the ninth 
day the inital loss has been made good. The following 
figures express the average daily loss and gain during 
the first six days of life — : 

First day Loss of 139 grams, or nearly 5 ounces. 

Second day Loss of 64 grams, or nearly 2\ -ounces. 

" Third day Gain of 33 grams, or about 1 ounce. 

Fourth day Gain of 50 grams, or about if ounces. 

Fifth day . . Gain of 50 grams, or about if ounces. 

Sixth day Gain of 36 grams, or about 1 \ ounces. 

The child's weight should be doubled in the fifth 
month, and trebled in the twelfth month. The baby 
should be able to hold up its head in the sixteenth week, 
at the same time sitting up. It should stand by the 
thirty-eighth week. It should "take notice" and be 
able to grasp things by the third to the fourth month. 

It is important that a nurse should know the above 






FEATURES OF INFANCY IN HEALTH AND DISEASE. 217 

facts as to the child's development, to be able to report 
satisfactorily concerning its condition to the physician 
in attendance. 

Sleep. — A large proportion of the time of early in- 
fancy is spent in sleep. The more premature the baby, 
the more constantly does it sleep. During sleep the 
eyelids should be tightly closed. A partial separation 
of the lids, showing the whites of the eyes, is an indica- 
tion either of some disease, or of pain, from whatever 
cause. 

The Respirations of a healthy baby when awake may 
be very irregular, some inspirations being shallow and 
others deep — at times hurried, and again slow. The 
only time when the respirations can be satisfactorily 
counted is when the child is asleep, for then the breath- 
ing is more regular. The rise and fall of the abdomen 
may then be noted (for the breathing of an infant is ab- 
dominal). The number of respirations in a minute 
averages 44. So quiet is the healthy breathing of early 
infancy that there is no motion of the nostrils or of the 
lips, or even of the chest, to indicate the incoming and 
outgoing of air. Fever, colic, and lung trouble will 
greatly increase the number of respirations in a minute, 
making them mount up to 60 or 80, or even higher. 
Nervous excitement has a similar effect, though this is 
temporary. 

In brain trouble a slowing of the respirations occurs, so 
that they may get down to eight in a minute. When 
the act of breathing is painful, a moan or cry accompanies 



2l8 OBSTETRIC NURSING, 

each act of respiration. The expansion of the nostrils 
with each inspiration indicates a want of sufficient air 
space in the lungs. In connection with any lung trouble 
a bluish coloration of the lips and face generally is a bad 
symptom, as it indicates that sufficient air does not 
enter the lungs to purify the blood. 

The Pulse. — Little reliance is to be placed upon the 
pulse of a baby as indicative of disease, for it is charac- 
teristic of the infantile pulse that it is very rapid, very 
easily affected by external or internal causes, and not- 
ably irregular. The average pulse of the new-born 
baby is 140. If a baby is well-nourished, it is too fat to 
enable the pulse in the radial artery to be counted. 
Hence the pulse is more easily obtained in the temple or 
at the ankle. If not thus readily obtained, the heart- 
beats may be counted by holding the hand over the 
baby's heart. 

The Temperature of a child at this age is also subject 
to rapid changes, the result of slight causes. The aver- 
age temperature is 99 Fahr., but a cold or an attack 
of indigestion may cause a sudden increase, with as sud- 
den a return to normal when the cause is removed. 

A subnormal temperature is an indication of lowered 
vitality, the result of some drain upon the system, as of 
an exhaustive diarrhea, or of some constitutional weak- 
ness. This fall of temperature is a dangerous symptom 
in infants. The tip of the nose and the extremities of 
the child, if cold, also indicate a condition of low vitality 
and require that the child should receive very especial 



FEATURES OF INFANCY IN HEALTH AND DISEASE. 219 

care from the nurse as to the supply of food and warmth. 
In fever the back of a child's head feels very hot, as also 
do the palms of the hands. 

The Cries of a Child form a special language by which 
its needs may be made known. Every nurse should 
learn to distinguish the peculiarity in the different kinds 
of cries, so as to meet the varying demands thus indi- 
cated. A healthy, well-trained baby rarely cries, unless 
hungry, when the cry will be constant and very persist- 
ent until the want is satisfied ; the upper part of the body 
is moved at the same time, especially the arms and head. 
The cry induced by ear-ache is also unappeasable, and 
generally accompanied by a drawing of the hand up to 
the head. A similar gesture accompanies the cry in- 
duced by brain trouble, which is a shrill scream, often 
waking the child during sleep. 

A cry accompanying a cough is an indication of pain in 
the chest. The paroxysmal character of colic is indi- 
cated by the characteristic cry which accompanies it, — a 
sharp, sudden cry, — the limbs at the same time being 
drawn up toward the abdomen. An evacuation of the 
bowels may precede or follow the cry. 

Sore Mouth. — If, in nursing, a baby seizes the nipple 
by the month and drops it suddenly with a cry, doing 
this repeatedly, there is in all probability some soreness 
of the mouth, which should be discovered and treated. 
However heartrending the cry, the baby does not secrete 
tears in sufficient quanity to run down the cheeks until 
the third month of infancy. Hence the common saying 



220 OBSTETRIC NURSING. 

that a baby cannot suffer pain because it sheds no tears 
while crying is not supported by fact. 

Facial Expression. — A wrinkling of the forehead 
vertically, produced by drawing the eyebrows together, 
indicates pain about the head. A sharpening or play of 
the nostrils exists in lung troubles. A drawn look about 
the mouth is found with digestive troubles, as flatulent 
colic. 

The Stools of a very young baby fed on breast milk 
should be of a yellow or orange color. Three or four 
evacuations a day are natural. They should contain no 
curds. Stools of bottle-fed babies are lighter, more 
offensive and less frequent. 

Urination. — The number of times a new-born baby 
urinates will vary much with the weather and the condi- 
tions under which the child is placed. It is not unusual 
in cold weather for the napkin to need changing almost 
every hour. Healthy urine should not stain the napkin . 

Mothers and nurses are often much troubled by the 
failure of an infant to pass urine or feces for the first few 
hours or days of its life. A careful examination of the 
anus or external opening of the bowel will soon show 
whether there is any imperforate condition of the rec- 
tum which may cause the retention of feces. Closure of 
the urethra is so rare that retention of urine is very sel- 
dom seen. 

The new-born infant secretes but very little urine 
until it begins to take nourishment freely. The bladder 
is usually emptied during the process of birth, which is 



FEATURES OF INFANCY IN HEALTH AND DISEASE. 221 

very frequently the case with the bowels, so that if the 
child seems well and there is no malformation of the 
parts, the family may be assured that the condition is 
only temporary. 

The use of fomentations over the kidneys and bladder 
will frequently hasten the evacuation of urine if it be un- 
duly delayed. If the secretion seems highly concen- 
trated, as is shown by the brickdust deposit sometimes 
found on the baby's diaper, a drop of sweet spirits of 
nitre in a teaspoonful of water may be given once in two 
hours. 

Should the child seem to suffer pain from the reten- 
tion of the contents of the bowel, an ounce of warm 
water or olive oil injected into the rectum will usually 
produce a satisfactory evacuation. Should a laxative 
by the mouth be needed, the physician must be con- 
sulted. A teaspoonful of sweet oil often serves the 
purpose very nicely, or a few grains of manna dissolved 
in milk. 

The Teeth sometimes appear prematurely. A child 
may be born with one or more teeth already cut. These 
are usually imperfect, and fall out in a short time, to be 
replaced by the milk-teeth. The latter are twenty in 
number, and are usually cut in groups, starting about 
the fourth month and continuing till between the twen- 
tieth and thirtieth months, when the first dentition 
should be complete. There is an interval of rest as a 
rule between the eruption of each group. Girls are more 
apt to cut their teeth early than boys, and, as an early 



222 OBSTETRIC NURSING. 

dentition is usually an easy one, it is fortunate for the 
child to have it occur early. 

Even under normal conditions the edges of the gums 
in teething become swollen, rounded, and reddened as 
the teeth come near the surface. The saliva is at the 
same time increased in quantity, and the mouth is heated 
and uncomfortable, so that the child desires constantly 
to bite upon any object that may be at hand. A 
healthy child should not suffer in any way from the 
process of dentition, and when the point of the tooth 
comes through the gum the local symptoms may vanish. 

The following diagram will illustrate the order in 
which the teeth are cut. The numbers i to 5 show to 
how many groups the several teeth belong and the or- 
der in which the groups appear. The letters a and b 
show the order in which the teeth in each group appear. 

Bottle-fed babies are more apt to be late cutting their 
teeth than those that are breast-fed. If no teeth have 
appeared when the child is a year old, we may know 
that the child's general nutrition is at fault, or it may 
have the disease known as rickets. 

Bottle-fed babies are also apt to have their teeth come 
through the gum in irregular order. This frequently is 
an indication of lack of health, although sometimes it is 
a family peculiarity. 

The first set of teeth which the child has is called the 
temporary set. It consists of twenty teeth, known as 
milk teeth. The permanent set, of which the first ap- 
pear at about six years of age, consists of thirty-two 



FEATURES OF INFANCY IN HEALTH AND DISEASE. 223 

teeth. They push upward in the jaw and loosen the 
first set, gradually displacing them. 

Walking. — Many children creep before they walk, 
and in that case may prefer this means of locomotion to 
walking. A child usually creeps as early as seven or 




Fig. 53. — Diagram Showing Eruption of Milk Teeth. 1 

1, 1. Between the fourth and seventh months. Pause of three to nine 
weeks. 2, 2, 2, 2. Between the eighth and tenth months. Pause of six to 
twelve weeks. 3, 3, 3, 3, 3, 3. Between the twelfth and fifteenth months. 
Pause until the eighteenth month. 4, 4, 4, 4. Between the eighteenth and 
twenty-fourth months. Pause of two or three months. 5, 5, 5, 5. Between 
the twentieth and thirtieth months. 

eight months. At about ten months the child may walk 
by holding on to things. Strong children may walk 
alone at one year of age. With weaker children this 
may be delayed until two years. 

1 From Starr, " Diseases of the Digestive Organs in infancy and Childhood. " 



CHAPTER XVII. 

THE AILMENTS OF EARLY INFANCY. 

It is not proposed in this chapter to take up all the 
ailments of infancy, for the term infancy comprises a 
time beginning with the birth of the child and lasting 
until the first dentition. 

The obstetric nurse remains with the patient from 
four to six or eight weeks. During this time many de- 
viations from the normal, healthy state may be met 
with in the child, and these she should be quick to ob- 
serve and know how to manage. 

Prematurity. — One of the most important conditions 
of this period is " prematurity,' ' a result of the too early 
birth of the child. 

A premature birth is one that occurs at any time after 
the child is " viable" — that is, capable of living after its 
birth. The term of viability has been set at twenty-eight 
weeks, or seven lunar months. Deliveries occurring 
previous to this time are called " miscarriages." 

It may be that, with improved methods of manage- 
ment, the period of viability may be placed at an earlier 
date, but this is as yet a matter for proof. 1 

1 The French claim that by means of gavage and the couveuse, or hatching- 
cradle, the actual period of viability has approached six months of intrau- 
terine life. 

224 



THE AILMENTS OF EARLY INFANCY, 



225 



It has geneially been conceded that a child born at six 
lunar months cannot live, that at seven months it stands 
little chance, that at eight months its chances are better, 
and at nine still better. 

The popular notion that an eight-month baby (count- 
ing the calendar month) does not stand so good a 
chance of living as a seven-month baby is altogether 
wrong. Great care is needed for premature babies. 




Fig. 54. — Tarnier's Couveuse. 
Dimensions of couveuse for a single infant: Width, 36 cm.; length, 65 
cm.; height, 55 cm. For twins a larger case is necessary. The temperature 
within the incubator should be kept at from 85 to 95 Fahr., as determined 
by a thermometer laid in upper compartment. 

They especially need regular feeding and to be kept very 
warm. The skin, being thin and delicate, will also re- 
quire very careful attention. 

Until within a few years the matter of keeping the 
baby sufficiently warm was exceedingly difficult to man- 
age. The French invention of the " couveuse," or 
" brooder," has simplified the matter very much. The 
15 



226 



OBSTETRIC NURSING 



first incubator for the rearing of premature infants was 
made in 1857, at Bordeaux. It was crude in construc- 
tion as compared with more modern inventions, but 
yielded very satisfactory results. In 1880 Professor 
Tarnier, of Paris, constructed an apparatus, consisting of 




Fig. 55. — Auvard's Couveuse (Interior View). 
In Auvard's couveuse a cylindrical reservoir of metal takes the place of the 
hot- water jars in lower compartment of Tarnier' s couveuse. This is filled 
by means of a metallic funnel fastened to one end of the box and cummunica- 
ing with the cylinder. An overflow pipe carries off the excess of water upon 
the addition of more hot water as required. — "Archives de Tocologies 



a box with an upper and a lower chamber, which com- 
municated with each other, and which was heated by 
stone jars filled with hot water in the lower chamber, the 
upper serving as the bed for the child. Suitable means 
for regulating the degree of heat were provided by venti- 
lators, etc. Dr. Auvard later improved this incubator 



THE AILMENTS OF EARLY INFANCY. 



227 



and presented it to the Maternity Hospital at Paris, 
where it served to prove most successfully that artificial 
means could be employed for increasing the chances of 
life with premature infants. 1 In 189 1 M. Lion, of Nice, 
improved upon any of the forms of apparatus earlier 
devised, and achieved the most wonderful results by his 
invention, which is now much used. 




Fig. 56. — Auvard's Couveuse (Exterior View). 



The Lion Incubator.—' 'The Lion incubator is composed 
entirely of metal and stands upon iron supports. It 
can be disinfected without deterioration by means of a 
steam stove under pressure. Ventilation is obtained by 
means of a tube of about three inches in diameter, with 

1 Crede's incubator is a copper vessel with double walls, between which 
water at the desired temperature may be kept, and withdrawn by means of 
pipes and stop-cocks. 



228 



OBSTETRIC NURSING 
M 





linliliniMILiilJiVlllllllJIIillilllllllln 

ill mi iii i mi 'i i in i hi mi inn hill in 

HilUllilliillllllllHI MjIWUII 

ifclVIbllliJtfllUklMI 

Ili&iifclBalttlllliiilllllbllrtlii. 




Fig. 57. — Incubator for Premature-born Children. 1 (Kny-Schcerer 

Co., New York.) 



THE AILMENTS OF EARLY INFANCY. 229 

a chimney of the same size. A screw placed on the top 
indicates by its rotation the strength of the current of 
air. The front of the incubator is fitted with a glass win- 
dow, through which the child may be seen, while on the 
left is another glass window, which enables the mother 
or nurse to attend to the wants of the infant, and, if 
necessary, to remove it. The baby is laid in a metallic 
hammock placed in the center of the incubator, thus 
enabling the warm air to circulate freely about it. A 
thermometer placed at the level of the infant's head 
regulates the working of the apparatus. The heating is 
effected by means of a siphon, through which the hot 
water circulates, and which communicates with a reser- 
voir at its side. A special system of pipes allows the air 
to pass directly from the exterior into the apparatus. 
In these pipes the air is filtered before it enters the incu- 
bator. The temperature is automatically regulated, 

1 The apparatus is constructed of steel, with glass doors and one glass 
window on the side for feeding purposes, etc. The heat generated in C com- 
municates itself to the water-filled tubes on the inside, maintaining a uniform 
temperature at any desired point by means of a spiral thermo-regulator inside, 
K, which is controlled by micrometer adjustment from outside. H and F. 
The hygrometer, L, records the atmospheric conditions of the chamber. 
The air supplied to the infant is filtered through an absorbent cotton filter in 
box A; this air can be taken from the room in which the apparatus is placed 
or directly from the outside by means of simple tubes. The revolving wheel, 
M, in chimney indicates the perfect circulation of air. The cup D is a feed- 
ing reservoir for the supply of water circulating in the pipes, and communicates 
with the siphon at the point E When the apparatus is in active use the cup 
will need filling about once in three hours. The gas-burner B is connected 
with a gas pipe in the apartment in which the apparatus stands, either by rub- 
ber tubing or, preferably, by close metallic connection. A thermometer is 
fastened to one side of the upper compartment of the apparatus. A frame 
for a chart containing records of the condition of the child is found on 
the top of the apparatus. 



230 OBSTETRIC NURSING. 

and the current of heat is increased or diminished as re- 
quired, and without variation. 1 " 

Modifications of the Lion incubator are made in this 
country. The accompanying cut shows the one in use 
at the Maternity connected with the Woman's Hospital. 

The child should be placed in the upper compartment 
of the couveuse as in its cradle, being removed simply 
for nursing, its bath, and toilette. If artificially fed, it 
can be managed through the side window, without re- 
moval from the incubator. When removed from the 
couveuse, care should be taken to have the temperature 
of the room sufficiently warm. It should be as nearly 
as possible the same as the temperature within the 
couveuse — between 87 and 90 Fahr. 

Auvard recommends the use of the couveuse in all 
cases where the vitality of the child is enfeebled either 
by external causes, as cold, or internal causes, as prema- 
turity, congenital feebleness, cyanosis, or "blue disease" 
wasting, or other general maladies enfeebling to the new- 
born. 

Swaddling. — Before the couveuse was known, pre- 
mature babies were swaddled in cotton, in order to be 
kept sufficiently warm. The directions for doing this 
are as follows: — ■ 

Take a square baby-blanket and place it diagonally 
on the table or bed. Turn down one corner for four 
inches' distance to come up over the baby's head. 
Spread over this blanket a lap of raw cotton. Have the 

^rom Catalogue of Lion Institute, Paris. 



THE AILMENTS OF EARLY INFANCY. 23 1 

baby's napkin and binder on, and a flannel undervest. 
Make a cap out of the cotton, fitting it over the baby's 
head and bringing it down well under the chin. Then 
roll the baby up in the cotton lap. Bring the blanket 
around this firmly, so as to hold it ; the portion of the 
blanket on the baby's right being brought over and 
tucked in on the left side, the portion on the left being 
correspondingly folded over toward the right. The cor- 
ner of the blanket left at the feet is then folded up over 




Fig. 58. — Swaddled Baby. 

the front, and the whole held by means of a strip of mus- 
lin bandage or ribbon. The bandage is first applied 
beneath the chin, crossed under the back, and again 
crossed in front, the ends being brought forward to 
fasten in a bow-knot at the feet. 

The great disadvantages of this method may be seen 
in the restriction it gives to the movements of the child's 
limbs, and the difficulty of determining when the child's 
napkin needs changing, also the frequent exposure of the 
child during these changes to the ordinary atmosphere. 

Home-made Incubator. — An ingenious method of 
maintaining the body-heat of a baby, and one readily 



232 OBSTETRIC NURSING. 

accomplished in any household, is described as follows 
by Dr. Reynolds: — 

" A large basket should be thickly lined with heated 
blankets or other flannels. A number of bottles, filled 
with very hot water, should be so arranged around the 
sides of the receptacle that they can be removed and re- 
inserted without disturbance of the infant. The child is 
wholly covered, with the exception of its face, with well- 
warmed cotton batting, and is laid between the bottles ; 
and the cradle is then covered with a thick blanket, a 
space at the end which corresponds to the child's head 
being left open to permit the entrance of air. A ther- 
mometer should be laid beside the child, and one or more 
of the bottles should be refilled with hot water whenever 
the temperature is seen to fall below 87 F. The water 
should not, on the other hand, be so hot as to raise the 
temperature of the contained air much above 90 F." 

Care of the Incubator Baby. — As soon as the cord 
is cut, the premature infant should be rapidly oiled with 
warm olive oil, wrapped in lamb's wool or absorbent 
cotton and placed in the warm incubator (87°-9o°). 
Feed the child every hour through the window of the in- 
cubator ; after each feeding, inspect the wool under the 
genitalia and change, if soiled; carefully change the 
position of the child from one side to the back, from the 
back to the opposite side, and so on regularly each hour, 
as there is danger of collapse of the lung from lying 
too long in one position. Always keep the child's face 
towards the window of the incubator. 



THE AILMENTS OF EARLY INFANCY. 233 

Constantly watch the temperature of the incubator 
and the revolving disk which shows the free circulation 
of air. Never leave the incubator immediately after 
turning up the gas flame w^hich regulates the temper- 
ature, for this may rise very rapidly and the infant 
may die from overheating. 

For the first week or sometimes longer, the infant 
must not be removed from the incubator for anv 
purpose. On the fifth day, change the dressings on 
the cord using every aseptic precaution for these infants 
are prone to septic infection of the cord. After one 
week if the child thrives, it may be removed from the 
incubator for a daily dip in hot water (103 ) followed by 
careful drying of the surface with a warm, soft towel. 
The skin under the arms, in the groins and around the 
genitalia must be mopped dry rather than wiped for 
there is great danger of abrading the delicate surface 
and subsequent infection. After drying, oil the body 
rapidly with equal parts w T arm olive oil and whiskey. 
Weigh the child every other day. By this time the child 
may wear a one-piece garment of flannel. 

Collapse of the lung — atelectasis — with death from 
asphyxia is a chief factor in the high mortality of 
premature infants, hence any evidence of cyanosis or 
arrest of respiration must be reported to the physician 
at once. Stimulation may be ordered — a drop or two 
of brandy with or without a drop of aromatic spirits of 
ammonia, in a teaspoonful of warm water every hour or 
two ; a hot bath followed by artificial respiration and 



234 OBSTETRIC NURSING. 

electricity may be required. A tank of oxygen should 
always be at hand. " 

Period of Incubation. — The length of time a pre- 
mature baby should be kept in its close quarters is de- 
pendant upon the progress it makes, or until the gain in 
weight and strength brings it up, as nearly as possible, 
to the standard of a baby at full term. A seven-months 
child, if strong enough, may be dressed and allowed to 
nurse when it is four weeks old. Great care, however, 
must continue to be exercised until the child reaches 
full term. It should not be removed permanently 
until it has acquired sufficient vigor to live in the 
ordinary atmosphere of the apartment. To accustom 
the child to this atmosphere, it should, as it grows 
stronger, be removed for an hour at a time from the cou- 
veuse during the warmest part of the day. 

It is best to continue the use of the apparatus at 
night for some time after the child becomes accustomed 
by day to removal from the couveuse, for the danger 
of chilling from changes in the atmosphere is greater 
at night. 

The child should be fed every hour. As it is usually 
too weak to suck, it is safer to feed the baby with a 
spoon or with a dropper, to make sure of its obtaining 
a sufficient amount of food. From one to two tea- 
spoonfuls should be given every hour. Make sure 
that the milk is actually swallowed; gentle strok- 
ing of the muscles at the sides of the throat may 
stimulate swallowing efforts where they are sluggish. 



THE AILMENTS OF EARLY INFANCY. 



235 



Breast milk is, of course, the best. It may be drawn 
from the mother's breast and fed to the 
child while warm. The nurse should 
introduce her little finger into the child's 
mouth and allow the milk to trickle 
slowly down the finger, so as to enter 
the mouth drop by drop, while the child 
sucks the finger. Should the mother 
have no milk, the first week's feeding 
recommended previously, or sterilized 
peptonized milk, diluted two-thirds with 
boiled and filtered water, may be used 
— if no wet-nurse can be had as a sub- 
stitute. 

Gavage. — Should the baby drink badly 
and vomit a large proportion of the 
liquid given to it, " gavage" may have 
to be resorted to. The physician must 
authorize the nurse to carry this out, 
for she should never undertake it other- 
wise. The directions for practicing 
gavage, as given by Dr. Louis Starr, 
are as follows: — 

The apparatus used is quite simple, 
being nothing more than a urethral 
catheter of red rubber (Nos. 14-16, 
French), at the open end of which a 
small glass funnel is adjusted. The infant upon whom 
gavage is to be practised is placed on the operator's 



\ 



Fig. 59. — Feeder 
for Premature 
Infants. {Cooke.) 



236 OBSTETRIC NURSING. 

knee, with its head slightly raised; the catheter, being 
wet, is introduced as far as the base of the tongue, 
whence, by the instinctive efforts at swallowing, it is 
carried as far down as the esophagus (or gullet) and 
into the stomach. 

The liquid food is next poured into the funnel, and by 
its weight soon finds its way into the stomach. After 
a few seconds the catheter must be removed, and here 
is the great point in the operation ; it must be removed 
with a rapid motion and at once, for if it be withdrawn 
slowly all the food introduced will be vomited. 

Mothers' milk is the best for gavage, as at any time, 
but other kinds of food may be used. The amount 
given and the number of meals will vary with the age 
and strength of the child. From a teaspoonful to a 
dessertspoonful at one time is sufficient for a very young 
child, given every hour. Too much food would produce 
indigestion. As the child grows stronger this mode 
of feeding may be made to alternate with nursing. Mod- 
ified cow's milk may be used for the alternate feedings. 

Colic is a very troublesome affection of infancy. It 
corresponds to the dyspepsia of grown people, and 
indicates that the food is either improper in quality 
or quantity. A colicky cry is a sudden, sharp cry, 
the baby drawing up its feet and legs at the same 
time. The feet are generally cold, and one indica- 
tion for treatment is to warm them; warm socks or 
woolen stockings should be worn or hot bottles applied 
to the feet. 



THE AILMENTS OF EARLY INFANCY. 237 

The abdomen should also be kept warm by the appli- 
cation of heated flannels, or a spice poultice, wrung 
out in hot whiskey, or a flaxseed poultice, which 
should be kept applied until the baby gets relief. 

To make a spice plaster, a teaspoonf ul each of ground 
allspice, cloves, cinnamon, ginger, with four teaspoon- 
fuls of flaxseed meal, may be quilted into a bag of flan- 
nel, 4x8 inches, which will fit entirely over the baby's 
abdomen. When the spicy smell is lost the plaster is 
no longer good for use. 

Warm oil rubbed gently in over the abdomen for 
ten to fifteen minutes at a time will often give relief 
by leading to the expulsion of the wind causing the 
pain. 

If the application of heat is not sufficient, anise- 
seed tea should be given. It is made as follows: — 

Over a half-teaspoonful of anise-seed pour a half- 
teacupful of boiling water. Allow it to steep a few 
minutes, until the water tastes strongly of the anise- 
seed. A half-teaspoonful of this may be given warm 
every ten minutes until the baby has had four doses. 
This brings up wind from the stomach, and thus 
gives relief. Simple hot water will help in the same 
way should anise-seed not be on hand. Catnip tea 
may be made and used according to the same direc- 
tions. These teas are preferred to the drop doses of 
gin so frequently given. 

Bowel Movements. — Frequent stools do not always 
indicate diarrhea. For the first six weeks of its life 



238 OBSTETRIC NURSING 

a child averages three or four movements every twenty- 
four hours, after which it has about two a day until it 
is two years old. 

A natural passage for an infant would be of a mushy 
consistency and a yellow or orange color. It should 
contain no curds larger than rice grains. Bottle-fed 
babies have whiter and more offensive stools than 
breast-fed babies. 

Diarrhea. — In diarrhea there is a change in con- 
sistence or appearance. A liquid stool or one colored 
green or white or like putty, would be abnormal. The 
presence of curds also would show an inability to di- 
gest the food properly. The diarrheas of infancy, 
though oftenest due to improper food, may be caused 
by exposure to heat, or may result from taking cold. 
Bottle-fed babies suffer much with diarrhea in sum- 
mer time, indigestion and heat acting together to pro- 
duce the disease. Often little can be accomplished 
without entire change of air. A trip to the seashore 
or the mountains has saved many a baby's life. 

In simple diarrhea there is little, sometimes no, fever. 
There may or may not be vomiting. In cholera in- 
fantum the stools are very numerous, the discharges 
being the color of rice-water. There is constant vomit- 
ing, high fever, intense thirst, great coldness of the 
surface, and often sudden collapse. 

In inflammation of the bowels the movements are 
smaller and have some color. The fever is more mod- 
erate and the vomiting is less. 



THE AILMENTS OF EARLY INFANCY. 239 

In dysentery the passages are frequent, small, and 
contain more mucus. There is much straining and 
often quite a large amount of blood passed. The ema- 
ciation of infants suffering from these diseases is very 
rapid. 

The careful regulation of the baby's diet is the most 
important consideration in treatment. Stop all milk 
for forty-eight hours. A little barley-water or egg- 
albumen water, or some simple meat juice may be used 
if the baby seems hungry. Cold water also may be 
given. If the baby's skin feels hot, it may be bathed or 
sponged with cool water frequently. If the surface 
is cold, a tepid mustard bath may be given. When 
the attack first begins it is well to clear the bowel of 
all irritating substances by a dose of sweet oil, to which 
(for an infant under two months) 15 drops of castor 
oil may be added. After this a little bismuth and 
chalk mixture is usually given by the physician, or 
small powders containing bismuth (about 1 gr.), once 
in two or three hours. The physician will usually 
determine the special remedy indicated after inspec- 
tion of the stools. 

Feeding in Indigestion. — If, therefore, curds exist in 
the stools, or the matters vomited be curdy, the indica- 
tion would be to use some alkali or a small quantity of 
some thickening substance, as barley-water, or gelatin, 
or the milk may be peptonized. 

Lime-water is the alkali most usually employed. 
Lime-water contains but about half a grain of lime 



240 OBSTETRIC NURSING. 

to the fluid ounce of water, so that at least a third of 
the feeding should be lime-water where it is used to 
correct indigestion. To make lime-water, a piece of lime 
about the size of the fist should be placed in an earthen 
vessel; about three or four quarts of water may be 
poured over this, strained thoroughly, and then allowed 
to settle. The water should be used only from the 
top of the vessel. It is better to filter it before use. 
The vessel may be kept filled with water so long as 
any of the lime remains in it, when dissolved it will be 
necessary to add more lime. 

When lime-water cannot be obtained, a small pow- 
der of baking soda — three or four grains — may be added 
to the nui sing-bottle. These rules apply when the 
baby is artificially fed. Should the baby be nursing 
from the breast, a teaspoonful of lime-water mixed with 
an equal quantity of boiled and filtered water may be 
given it before it is put to the breast each time. 

Barley- Water and Oatmeal-Water. — Of the thick- 
ening substances used to help in the digestion of food 
barley-water is one of the best. To make barley- 
water, a gill of boiling water should be poured over a 
teaspoonful of washed pearl barley, finely ground in 
a coffee-mill. Boil for a quarter of an hour, then strain. 
It should be mixed with milk in the proportions re- 
quired, two-thirds, a half, or one-third. A pinch of 
salt should be added to the mixture. Oatmeal-water 
is similarly made. 

Gelatin is sometimes used instead of barley-water. 



THE AILMENTS OF EARLY INFANCY. 24 1 

A piece an inch square of plate gelatin is put into a 
half tumblerful of cold water and allowed to stand about 
three hours. This may then be turned into a teacup 
and set in a pan of hot water and boiled. The gelatin 
thus dissolves, and when allowed to cool forms a jelly, 
of which one or two teaspoonfuls may be added to a 
feeding. 

Infants' Foods. — Of the various kinds of " infants' 
food," those in which the starch has been made into 
dextrine or grape sugar are the best. "Mellin's Food," 
"Horlick's Food," and "Eskay's Food" belong to 
this class. A teaspoonful of any of these dissolved in a 
little hot water — about a tablespoonful — may be added 
to the milk for the feeding. Special directions for 
the use of each are supplied by the manufacturers 
with packages of the food. These starch foods can- 
not be. well borne by a child before it is five or six 
months old, as a rule, because the secretion of saliva is 
necessary to the digestion of starch. 

Condensed Milk contains a large proportion of sugar, 
hence tends to make fat. It is not so nourishing as 
many other forms of food. Babies fed on it, though 
large, are generally far from strong, and are very apt 
to suffer from indigestion. 

Usage in Woman's Hospital. — A careful regulation of 
the diet for the early weeks of infancy, with the addi- 
tion of barley-water, lime-water, or gelatin, as indicated 
in place of plain water, has been found most satisfac- 
tory in the care of infants in the Woman's Hospital. 
16 



242 OBSTETRIC NURSING. 

The use of water alone as a diluent is preferred. The 
modified milk preparations of the Walker-Gordon lab- 
oratory in Philadelphia have also been used with great 
satisfaction. 

When curds are persistently found in the stools, espe- 
cially with older children, it is thought by some to be 
of advantage to slightly thicken the milk by the addi- 
tion of a little prepared wheat flour, barley, oatmeal, or 
Graham flour. The use of cereals for the purpose, however, 
is rather questionable, especially with young infants. 

Flour Ball. — In using wheat the following recipe may 
be employed: Tie a pint of dry wheat flour into a 
piece of stout muslin and boil nine hours ; scrape off the 
outer crust and the inside will be found to be a dry ball ; 
grate this as needed and add about two teaspoonfuls 
to a pint of water, which when boiled may be used in 
diluting the child's milk in the proportion desired, in- 
stead of using plain water. After the sixth month, four 
teaspoonfuls may be used in place of two. Dr. J. Lewis 
Smith recommends allowing the flour, tightly tied up 
in a bag, to stand under water for about a week, the 
water being allowed occasionally to boil during this 
time. The flour is thus rendered more digestible. 

Other Cereals. — Ground barley, oatmeal, or Graham 
flour may be boiled in water in the proportion of a des- 
sertspoonful to the pint. An equal quantity of milk 
may be poured in while the water is boiling, and the 
whole may be boiled together from about twenty min- 
utes to a half -hour and then strained. A pinch of salt 



THE AILMENTS OF EARLY INFANCY. 243 

should always be added. An ounce of cream and a 
little milk sugar may be added to this. Dr. Keating 
recommends this preparation as excellent for an infant 
after its fourth month, when he considers that it is best 
to make the use of the bottle alternate with the breast 
in the feeding of an infant, especially if the mother is 
not very strong. 

Weaning. — If the mother has substituted the bot- 
tle for some of the feedings as early as at the age of six 
months, the child will not suffer from the process of 
weaning. In fact, a child often weans itself, refusing 
to take the breast milk during the later months. The 
mother's milk, even in most favorable cases, is rarely 
sufficient nourishment for the child after it is a year 
old. If possible no change in the child's food should 
be made in the summer months. 

Substitutes for Milk. — When the child is very weak 
and vomits constantly, — milk, especially, seeming 
to disagree with it, — some of the following meas- 
ures may be resorted to: small and repeated 
quantities of barley-water, gum-arabic water, or wine- 
whey may be used, a teaspoonful every half -hour or 
hour ; sometimes the white of an egg may be shaken up 
in a bottle of warm water and a couple of grains of lac- 
topeptin or Fairchild's liquor pancreaticus may be added, 
with a little milk sugar, and this may be given the 
child in teaspoonful doses. As the child's stomach 
grows stronger, teaspoonful doses of peptonized milk 
may be tolerated. No child should be fed too contin- 



244 OBSTETRIC NURSING. 

uously on the prepared foods alone. Fresh milk should 
be used whenever possible, as a disease known as scurvy 
often arises from long use of stale preparations. The 
admixture of cream with water (i part to 5 or 6 of 
water) has already been referred to as a substitute when 
milk is not well borne. 

An occasional drink of water is essential to a baby, 
however young. The water should be boiled and kept 
air-tight to be free from germs. From a teaspoonful 
to a tablespoonful may be given occasionally during 
the intervals of nursing. Infants under four months 
of age should be fed upon milk alone in some of its 
forms. 

Milk Foods. — When breast milk cannot be had and 
cow's milk seems persistently to disagree; some of the 
"milk foods," as Carnrick's Soluble Food, Anglo- 
Swiss, Gerber's, or American Swiss, should be tried first 
before any preparation containing starch is used. Care 
must be taken to see that the preparations are fresh 
before using. 

The Farinaceous Foods, as Blair's Wheat, Hubbell's 
Wheat, Imperial Granum, and the home-made prepara- 
tions before described should not be used until the child 
is at least four months old, if at all. 

Liebig Foods. — If in the use of farinaceous food the 
child's bowels become constipated, or it suffers from 
colic, or is restless at night and loses its appetite, some 
of the Liebig foods may be tried, as Mellin's Malted 
Milk, Lactated Food, etc. The directions for the use 



THE AILMENTS OF EARLY INFANCY. 



245 



of these foods come with the various packages contain- 
ing them, and are readily followed. Milk, as a rule, 
in some form or other, should be used in making 
up these preparations ; otherwise they will not contain 
sufficient nourishment. 

Constipation is not an infrequent occurrence in infancy. 
Its management consists principally in the use of 
mechanical irritants for stimulating the 
bowels; thus, a soap suppository, an 
injection of warm oil or water, gentle 
friction over the bowel, especially fol- 
lowing the direction of the large bowel 
from right to left, are among the most 
effective methods for overcoming this 
condition. 

The soap suppository is made by tak- 
ing a piece of Castile soap, about one 
inch long, and shaping it into a cone and 
making it very smooth, so that it will 
not be larger around than the end of the 
little finger. This should be gently in- 
sinuated about half its length into the Fig. 60.— Single- 
bowel and held in the opening until it (Starr.) 

excites the bowel to act. 

The bowel injection may be given by means of the 
single-bulb syringe, known as the ' ' eye and ear syringe. ' ' 
The bulb holds about two tablespoonfuls of liquid. 
This may be warm cotton-seed oil, sweet oil, or warm 
water. The nozzle used should be small, smooth, and 




246 OBSTETRIC NURSING. 

well oiled. It should be very caiefully introduced into 
the bowel, being directed a little to the left side, and the 
bulb gently squeezed to force the contents into the 
bowel. It is best that the liquid should be retained 
for a little time before it is forced out. The keeping up 
of a slight pressure over the entrance to the bowel for 
a short time will aid this. 

Rubbing the abdomen for about ten minutes (either 
with or without oil) in the direction of the large bowel — 
that is, upward on the right side as far as the border of 
the ribs, then across to the left side and down this to 
the pelvis, is often efficient in overcoming constipa- 
tion. 

Of Medicinal measures, glycerin, gluten, or cacao-but- 
ter suppositories may be resorted to, or manna may be 
given; a piece the size of a pea in the child's milk one, 
two, or three times a day, or a spoonful of water sweet- 
ened with dark-brown sugar. Should the child be fed 
on artificial food, oatmeal water may be substituted for 
barley-water in the preparation of the food. If nurs- 
ing, oatmeal water may be given it (1 tablespoonful) be- 
fore each nursing. 

Rupture, or Hernia, is a protrusion of the bowel 
through some weak point in the abdominal walls. It 
very often occurs at the navel and sometimes in the 
groin The best treatment for the former consists in 
drawing together the edges of the hernial opening by 
means of a strip of adhesive plaster. A truss will need 
to be fitted for the other form. 



THE AILMENTS OF EARLY INFANCY. 247 

Vomiting. — Babies vomit very easily, because their 
stomachs are placed more vertically in the body than 
when they grow older, and overfeeding will cause them 
to bring up the amount in excess of what the stomach 
can hold. This vomiting is, of course, not serious. 
Should the vomited master be sour and curdy, the 
child seem to suffer from nausea, weakness, or fever, 
it indicates a condition of indigestion which should re- 
ceive attention. The management would largely con- 
sist in the regulation of the quality and the quantity 
of the food, as has just been said. It is best to withhold 
food for several hours, and modify its character when it is 
resumed, as described above. A spice-plaster over 
the stomach is often helpful. When the vomiting is 
due to overeating, the amount of food taken at one 
time must be regulated. 

Worms. — There are three different kinds of worms 
which may exist in children, but young infants are 
troubled, as a rule, with one kind, the thread or seat- 
worm. These look like little pieces of white cotton 
thread, and the stools should be carefully examined 
when suspected. They make the parts around the 
lower bowel very sore and produce intense itching. 
The parts should be kept very carefully cleansed, 
and a bowel injection of salt and water or of a little 
infusion of quassia may be given every day or so. 

The tape-worm and round-worm are found in older 
children. 

Thrush is a disease due to want of care of the baby's 



248 OBSTETRIC NURSING. 

mouth. If milk be allowed to collect on the tongue, 
it sours, and the presence of this acid favors the de- 
velopment of thrush, which is really a vegetable parasite. 
White patches may be seen on the soft palate, in- 
side the cheeks, lips, and tongue. The attempt to 
rub off these patches causes bleeding. Gastric catarrh 
and diarrhea usually accompany this trouble. Care in 
cleansing the child's mouth after each nursing will pre- 
vent the occurrence of thrush. Its treatment consists 
in the use of an alkaline wash, as borax and water 
(twenty grains to the ounce), or some antiseptic 
wash prescribed by the physician.* 

Birth Marks — that is, the purplish-red patches or 
the moles sometimes found on a new-born baby — are 
not dependent in any way on the mental impressions of 
the mother. They can often be removed by treatment. 

Red Gum is an eruption which comes out over the 
baby in the first or second week of its life. Sometimes 
these little points of elevation on the skin are white. 
The eruption is then called "white gum. " These 
eruptions are due to changes in the skin and irritation 
from exposure to air, and are not serious. They rarely 
last over a week, although they may persist for several 
weeks in babies of delicate skin or poor digestive powers. 
They are also known as strophulus. 

*Boric acid (ten grains to the ounce of water) is very good. A teaspoonful 
of this may be swallowed by the child occasionally. Of late a solution one 
part hydrogen dioxide to eight of witer has been much used. This fol- 
lowed by the boric-acid wash. After which a little bismuth subnitrate may 
be applied over the sore spots. 



THE AILMENTS OF EARLY INFANCY. 249 

Blisters. — The occurrence of little blisters on the 
child's body, especially on the palms of the hands and 
soles of the feet, is a matter of more moment and should 
at once be brought to the attention of the physician, as 
also should sores, around the finger nails. These in- 
dicate a condition of the blood for which the use of 
remedies prescribed by the physician will be necessary 
The technical name for the rash is pemphigus. 

Prickly Heat, or Miliaria, consists of pin-head sized 
red elevations closely crowded over the portions of 
the body where there is most perspiration. It often 
results when children are too warmly dressed, or in hot 
weather. The treatment consists in the substitution 
of lighter clothing, with the relief of the skin irritation 
by the use of some powder, as camphor, one part to 
eight parts powdered starch. A little magnesia may be 
given by mouth. 

Stomach Rash is a name given to an eruption known 
as erythema — a redness of the skin, with the occurrence 
of pimples — caused by indigestion. 

Eczema is a disease which is much more trouble- 
some. It may last months. There is usually an in- 
herited tendency to some constitutional trouble ; or im- 
proper food (especially starchy foods) or imperfect 
hygiene may be responsible for it. The surface is 
swollen, red, and moist ; thick crusts often form. There 
is intense itching. Such cases should always be under 
the care of a physician. A saturated solution of 
salicylic acid, with the subsequent application of zinc 



250 OBSTETRIC NURSING. 

ointment, often greatly relieves the distressing symp- 
toms, and in time removes the rash. 

Milk Crust consists of large, yellowish patches on 
the head, and is really dandruff. Castor-oil should be 
used to remove the patches, and the head kept cleansed 
with borax and water. 

The Whites. — Sometimes a whitish, glairy discharge 
comes from the privates of little girl babies. This is 
simply the matter found there at birth. Occasionally 
a little blood may be mixed with it, the result of an 
abrasion in the vagina, and may last a day or two. The 
nurse need not be afraid to remove this matter; in fact, 
if left, it causes irritation of the skin. 

Suppression of Urine. — A healthy baby usually wets 
its napkin very frequently — it may be every hour dur- 
ing the day, and four or five times at night. Some- 
times several hours may pass and yet the napkin re- 
main dry. Either of these conditions may exist in 
health, being dependent largely upon the weather, 
the food, etc. If urine is not passed for twelve hours, 
the condition should be reported. 

The nurse may try to make the baby urinate by 
using fomentations over the bladder and kidneys before 
reporting the matter to the physician. If a baby cries 
when urinating, a careful examination must be made of 
the water-passage to see whether there is any cause for 
irritation, as the urine may be irritating. In boy babies 
there is sometimes a very long narrow fore-skin which 
tends to become adherent to the parts beneath it. 



THE AILMENTS OF EARLY INFANCY. 25 1 

Phimosis is the name given this condition. For its 
management a nurse should be taught to retract the 
foreskin daily, oiling the surface beneath with a little 
castor-oil applied with a camel's hair brush or stick 
twisted with cotton. For irritating urine, giving the 
baby frequently a drink of cold water is usually suffi- 
cient. 

Chafing. — The skin of new-born babies is soft and 
thin, and apt to become sore, especially when two sur- 
faces rub. First, a little crack is noticed, next day this 
will have widened until, sometimes, a large surface is 
left bare. To prevent this, proper care of the baby 
from the very beginning is important. Never use 
soap. Use warm water in washing it, either plain 
warm water or water with sufficient powdered borax in 
it to make it soft, and wash the part very carefully ; wipe 
or mop with a soft cloth until throughly dry. Then, 
to prevent further rubbing, carry a piece of dry steril- 
ized gauze into the crease between the rubbed sur- 
faces, separating them. This should be changed when- 
ever the baby's napkin requires changing. 

When the skin is broken, some healing ointment is 
generally required. The following has proved very 
satisfactory: An ointment consisting of two drams 
of bismuth subnitrate to the ounce of zinc ointment, or, 
preferably, lanolin. A paste of equal parts of bismuth 
subnitrate and castor-oil is also useful for the pur- 
pose. 

Boils. — When run down or suffering from chronic 



252 OBSTETRIC NURSING. 

digestive troubles, babies often suffer from boils 
or other pustular eruptions. They may arise, too, 
from conditions of constitutional disease. When these 
need to be poulticed, the only kind of poultice admis- 
sible is an antiseptic poultice made by wringing out sev- 
eral folds of clean, soft, linen or gauze in a hot satura- 
ted solution of boric acid and covering this with a 
piece of rubber tissue or paraffin paper to retain the 
heat. A little ointment containing ichthyol is good 
in the early stage. When pus exists, the boil should be 
lanced. Change of air with tonics will often do much 
to relieve this tendency. 

Fever Blisters. — Children should be kept from pick- 
ing these blisters, which may be treated by the appli- 
cation two or three times a day of the bismuth and 
zinc ointment or any healing ointment. 

Itch is a contagious skin affection, usually found 
among the dirty, but may be contracted by the clean- 
est children. The sides of the fingers, the toes, the 
buttocks, may be covered with small pimples and ir- 
regular ridges where the parasite has burrowed. There 
is intense itching. The thorough and careful use of 
antiseptics under the direction of a physician will be 
necessary for cure. 

Ringworm is also a contagious skin affection due to 
a fungous growth. The ring-like shape gives it its name. 
Sulphur and tar ointment make a good application for 
this. Ringworm of the scalp is very difficult to cure, 
and should be seen by a doctor. 



THE AILMENTS OF EARLY INFANCY. 253 

Baby's Sore Eyes. — There are two forms of inflamed 
eyes occurring in new-born infants ; the first a simple 
catarrhal condition of no serious import; the other, 
a highly contagious, purulent inflammation of the 
conjunctival sack the result of infection by the organism 
of gonorrhea and termed ophthalmia neonatorum. 

Ophthalmia Neonatorum usually manifests itself on 
the third or fourth day; the eyelids are swollen, ede- 
matous and tightly closed ; from between them oozes 
thick, greenish-yellow pus; upon opening the lids the 
mucous membrane lining them is found intensely red, 
swollen and bathed with thick pus. The conjunc- 
tiva covering the eye-ball is next involved and even 
ulceration of the cornea may result; these ulcers in 
healing may leave scars which forever shut out "the 
blessed day light." Thirty out of every hundred 
cases of blindness are due to this preventable disease 
of infancy. 

Ways of Infection. — i. If the mother is a victim of 
gonorrheal infection, the discharges bathing her vagina 
and vulva teem with gonococci which are deposited 
upon the child's lids during its birth. As soon as 
the child opens its eyes, this infectious material enters 
the conjunctival sac and the mischief is done. 

2. The mother's or nurse's fingers may come in con- 
tact with infectious material about the vulva. If the 
infant's eyes are touched with these unclean hands, 
or if hands soiled with the mother's secretions are used 
about the child's face, infection promptly occurs. 



254 OBSTETRIC NURSING. 

3. In institutions, one unsuspected case of ophthal- 
mia may lead to several others, the infection being 
carried from child to child by the nurse's hands. 

Methods of Prevention. — Immediately after deliv- 
ery, cleanse the eyes with a saturated solution of boric 
acid. Use pieces of old, soft linen ; wipe from the inner 
angle of the eye to the outer and throw the cloth away, 
repeat several times and treat the opposite eye in 
like manner, being sure to attend to this before the child 
has a chance to open its eyes. This is something for 
the nurse to do, in all probability the doctor will be 
occupied with other matters but the nurse can con- 
centrate her attention upon the child's eyes as soon 
as the head is born. 

Crede's Prophylactic Disinfection. — Crede, in his lying- 
in hospital in Leipsic, succeeded in reducing the fre- 
quency of ophthalmia from 13 per cent, to 1 percent, 
by instilling one drop of a 2 per cent, solution of silver 
nitrate in each eye immediately after the birth of the 
child. It is now universal practice to treat all hospital 
cases by this method as well as all suspicious cases in 
private practice. 

Treatment. — Report immediately the presence of any 
discharge about a baby's eye. The doctor will at once 
make a smear and examine the discharge under the mi- 
croscope. If gonococci are found, the child must be 
isolated with one or more conscientious nurses, the fate 
of the child's eyes restsjn large measure with the nurse. 

If there is one well eye, this must be sealed with cot- 



THE AILMENTS OF EARLY INFANCY. 255 

ton and bandaged. Raise the bandage with disinfected 
hands and inspect this eye three times a day. Always 
lay the baby with the sore eye down. Douche the af- 
fected eye once every hour with a warm saturated 
solution of boric acid until free from pus. The best 
outfit for this purpose consists of a douche can, rubber 
tubing and bulbous tipped eye dropper. Place the baby 
on a table with its arms fastened to its sides and its head 
(sore eye down) on a Kelly pad. Gently separate the 
lids with the thumb and finger of one hand while the 
other hand holds the eye dropper and directs the flow 
from the inner to the outer angle of the eye. 

In the intervals of douching, apply cold compresses 
to the lids. These are flat pads of absorbent cotton the 
size of a five-cent piece. Place a block of ice in a basin 
and arrange a goodly number of cotton balls upon it. 
The nurse seats herself comfortably at the child's head 
and places one compress on the lid, leaves it there one or 
two minutes then drops it in a pus pan and replaces it 
by a fresh pad. Keep this up without intermission for 
twenty minutes out of every hour. 

Twice in twenty-four hours a 50 per cent, solution 
of argyrol may be ordered dropped in each eye. If 
ulceration of the cornea occurs, the pupil must be dilated 
with atropin. 

Throughout the treatment of these cases the nurse is 
in imminent danger of infecting her own eyes. The 
greatest danger lies in the spattering of pus during the 
borkfacid irrigation ; throughout this process the nurse 



256 



OBSTETRIC NURSING. 



must wear large spectacles or preferably automobile 
goggles which are provided with shields. While hand- 




Fig. 61. — Arrangement for Irrigation or the Eyes. 
The pledget in the left hand is placed against the cheek to prevent the 
fluid from getting into the nostrils and mouth. (De Lee.) 

ling the child, she should wear rubber gloves. Before 
touching her own eyes, making her toilet, or going to 
meals, her hands must be washed for ten minutes in 



THE AILMENTS OF EARLY INFANCY. 257 

soap and water and disinfected for two minutes in bi- 
chlorid solution i- 10,000. If any pus accidentally 
reaches the nurse's eyes she must report to the physician 
immediately and not wait for symptoms to appear. 

The poison is much more virulent in adults than in in- 
fants and many a valuable nurse has become perma- 
nently incapacitated through failure to carry out these 
precautions. 

Upon discharge from isolation the room occupied by 
baby and nurse must be fumigated. 

There is a law in many States, Pennsylvania included, 
requiring nurses or mothers having an infant in charge 
who is not under the care of a medical attendant to re- 
port promptly to the Board of Health any appearance 
of inflammation about the eyes. 

Snuffles, or a Cold in the Head, shown by watery eyes, 
sneezing, stopping up of the nose, hence difficulty in 
nursing, should be managed by keeping the nose cleaned 
out by means of soft linen twisted into a cone, greasing 
the nose well afterward with a little oil by carrying it up 
the nostrils on a twist of cotton, greasing the outside of 
the nose between the eyes, and keeping the baby warm. 
If the baby has no hair, the head may be kept warm by 
a little mull (or in winter thin flannel) cap. Sometimes 
a little nitre-water or some tonic may be required. 
Usually a dose of oil should be given, as 10 minims cas- 
tor-oil with 1/2 teaspoonful sweet oil at first, followed 
by warm drinks. 

Running at the Ears is generally very serious in new- 
17 



258 OBSTETRIC NURSING. 

born babies, especially when the discharge is matter or 
blood. Some trouble with the brain may be threatened, 
hence the physician should be told of it as soon as it 
is noticed. Of course, the discharge entering the ears at 
the time of the birth should be carefully excluded from 
this disorder. 

Earache. — A persistent cry, with the raising of the 
hand constantly to the head, will often indicate earache. 
The pain is often relieved by holding a hot water bag or 
bottle to the ear. Relief is also often obtained by syr- 
inging the ear with water as hot as can be borne, after 
which a drop of warm oil or glycerine with or without a 
drop of laudanum may be dropped into the ear. This 
should be done frequently, and the ear kept covered in 
the intervals with hot, dry flannel. 

The Breasts of new-born babies often swell. Generally 
this occurs about the seventh day or during the sec- 
ond week. Occasionally they gather, and must then be 
lanced by the physician. Nothing should be done for 
this swelling, except to see that the clothing is loose. 
It disappears in a few days, as a rule. 

Scalp Tumors. — The same may be said of swellings on 
the head or about the face, which are due to pressure 
during the birth. One form of scalp tumor may last 
several weeks before its entire disappearance. The lat- 
ter is the result of temporary injury to the bone, and not 
simply the ordinary swelling which comes from inter- 
ference with the circulation of the blood in the soft tis- 
sues of this portion of the scalp. The name blood-tumor 



THE AILMENTS OF EARLY INFANCY. 259 

{hematoma) is applied to this. No active treatment for 
its removal is necessary. 

Deformities. — A child may be born with some deform- 
ity, as hare-lip, or cleft-palate, or club-foot, or extra fin- 
gers and toes, or there may be some malformation about 
the external organs of generation or the bowel. The 
bowel passage may be closed, or there may be no open- 
ing from the bladder. Whatever the deformity may be, 
the nurse should avoid letting the mother know any- 
thing about it until the physician has told her of it. 
The shock produced by the knowledge may do the 
mother much injury ; hence the physician should bear the 
responsibility of making the announcement. A nurse 
will need considerable tact in managing this, as the 
mother is apt to ask to see her baby very soon after its 
birth. An excuse maybe made by stating the necessity 
for washing and dressing the child first, or it may be 
asleep and the nurse hesitate to disturb it. A child 
with hare-lip or cleft-palate will need to be fed, as a rule, 
with the spoon or a dropper, as it cannot nurse. 

Tongue-tie. — Quite frequently the bridle beneath the 
baby's tongue is too short, and interferes with the free 
movement of the tongue. This is called " tongue-tie.' ' 
It may prevent the child's nursing, and thus interferes 
with its nutrition. If the baby can extend the tip of the 
tongue beyond its lips, it is not probable that there will 
need to be anything done, as the baby ought to be able 
to suck a good nipple with ease. If the nurse should 
introduce the tip of her little finger into the baby's 



260 OBSTETRIC NURSING. 

mouth and allow the child to draw on it for a few min- 
utes, she can tell whether the act of sucking can be prop- 
erly accomplished. Should it not be able to suck, the 
attention of the physician should be called to the mat- 
ter, as the bridle will have to be nicked — an operation 
following which there may be considerable loss of blood, 
hence it should not be attempted except by a physician. 

Bleeding from the Cord or navel string may occur 
within a few hours after birth. It may be that the cord 
has not been tied sufficiently tight, or there may have 
been a very thick cord, which, in shrinking, has'loosened 
the ligature. If the cord has been tied in a single 
double bow-knot, this may be untied by the nurse and 
fastened more tightly, so that the bleeding may be con- 
trolled, or another ligature may be thrown around the 
cord a little nearer the body of the child than the first 
one. Should this not check the hemorrhage, the nurse 
should hold the cord firmly between the thumb and 
finger, making compression until the physician, who 
should be sent for, arrives. 1 

Falling of Cord. — The cord commonly falls off about 
the fifth day. The process of ulceration, by which it 
falls off, leaves an open surface on the child's body 
which offers an avenue for septic infection. Great care 
should therefore be taken that the nurse's hands and 

bleeding from the base of the stump after the cord has fallen is a more 
difficult condition to manage. The physician needs sometimes to control the 
hemorrhage by a ligature drawn beneath transfixion pins. The nurse must 
keep up pressure over the site until the doctor comes. If this is a simple 
oozing, a free application of powdered tannic acid with a compress is all 
that is necessary. 



THE AILMENTS OF EARLY INFANCY. 26 1 

anything else that comes in contact with this surface are 
perfectly clean. Should any moisture exist about the 
stump, the use of the antiseptic powder of salicylic acid 
and starch, before spoken of, or some other drying pow- 
der of the kind, may prove useful. It is necessary, also, 
to see that the dressing used is thoroughly antiseptic. 
When infection does exist, it shows itself in the occur- 
rence of inflammation around the navel or some other 
part of the body ; the child loses flesh, has fever, becomes 
puny and emaciated, and abscesses form in various 
places. In the majority of cases it dies, not having 
sufficient vitality to survive the poisoning. 1 

The physician will, of course, prescribe the treatment 
for such a child ; the nurse will be required to see that 
these directions are faithfully carried out, and especially 
that the child gets the nourishment and stimulation 
required. 

Umbilical Vegetations are either soft, jelly-like 
growths, or, what is more common, hard protuberances 
sometimes the size of a hickory-nut. They are not 
painful and seldom bleed. The physician sometimes 
removes them by ligature. The softer forms may be 
touched with caustic and thus made to shrink. When 
an ulcer exists at the place from which the cord dropped, 
dry antiseptic dressings or a drying powder, as boric 
acid and zinc oxide or a little tannic acid powder should 
be kept applied. 

Jaundice. — A peculiar yellowish coloration of the skin 

1 Sometimes the inflammation takes on the character of erysipelas. 



262 OBSTETRIC NURSING. 

is to be noticed with babies a few days after the birth. 
This disappears, as a rule, by the end of the second week 
and is due to changes in the circulation. 

Should the jaundice be very marked and seem to per- 
sist, warm baths once or twice a day, with gentle friction 
over the liver with soap liniment, helps, with free action 
of the bowels, to overcome the condition. Jaundice of 
the new-born baby is sometimes the result of disease of 
the liver. The color is then very marked. The baby 
grows thin rapidly and appears sick. The stools are apt 
to be clay-colored. When the child is suffering from 
blood-poisoning, the peculiar coloration of the skin is 
due to this cause. 

Buhl's Disease and WinckePs Disease are obscure 
conditions in new-born babies, thought to be due to fatty 
degeneration of the internal organs. They result fatally, 
as a rule, within the first few days of life. There is a 
tendency to hemorrhage from various parts of the 
body. 

Bleeders. — In some families, known as " bleeders," 
the tendency to hemorrhage may be transmitted to the 
child, particularly if it be a boy. It is necessary to 
watch for any such tendency very closely. The hemor- 
rhages may occur from any open surface on the body, or 
from the mucous surfaces. Tarry stools occurring after 
the normal bowel passages have been established would 
be an indication of intestinal hemorrhage. Sometimes 
the hemorrhage is in the brain and the child dies with 
symptoms of brain trouble. 



THE AILMENTS OF EARLY INFANCY. 263 

Convulsions may occur in very young infants at 
varying periods after their birth, according to the cause 
which excites them, as injury during labor, indigestion, 
brain trouble, or other causes. The convulsive seizure 
is generally preceded by twitching of the limbs, a rolling 
up of the eyeballs, so that a large part of the whites of 
the eyes is seen, the thumbs are drawn into the palms of 
the hands, and the fingers tightly clasped over them, or 
the toes may be turned upward or drawn downward. 
During the convulsion the child grows rigid. 

When the attack comes on the nurse should quickly 
undress the child and place it in a warm bath. A table- 
spoonful of mustard added to the water will help to 
stimulate the skin, and the convulsion will gradually 
subside. The child, on its removal from the bath, may 
be wrapped in a heated blanket, and allowed to perspire 
freely. On the recurrence of the convulsion, the same 
measure of placing the child in the bath should be re- 
sorted to, until the physician comes and instituties such 
other treatment as he may think proper. The use of an 
ounce of milk of asafetida by bowel is often efficient in 
quieting nervous irritability. 

Bruises, the result of falls or blows, should be treated 
by the repeated application of hot or cold compresses. 
This will relieve pain and prevent swelling and the 
black and blue discoloration of the skin which would 
otherwise result. 

The occurrence of a fall or blow should always be at 
once reported by a nurse, as the child should be carefully 



264 OBSTETRIC NURSING. 

examined for the discovery of any injury the serious 
consequences of which may be averted by prompt treat- 
ment. The occurrence of paleness or vomiting after any 
such accident is a serious symptom, and should receive 
immediate attention by the physician. 

Fever. — A hot, dry skin may accompany various of 
the disorders of infancy, notably inflammatory condi- 
tions of the digestive organs and of the lungs. The nor- 
mal temperature of a new-born baby is 99 Fahr., the 
pulse 140, the respiration 44. 

Should the child seem to be ailing, its temperature 
should be taken. A clinical thermometer may be held 
the requisite number of minutes in the groin or in the 
folds of the neck. Some slip the bulb of the thermome- 
ter into the rectum. Should the temperature be raised, 
the pulse rapid, and the respiration hurried and difficult, 
some lung trouble probably exists. Pneumonia is a very 
common disease with infants. A catch in the breath, 
noisy breathing, a distention of the nostrils on taking an 
inspiration, would indicate the same thing. The fre- 
quent rubbing of the chest with some counter-irritant 
liniment, as Compound Camphor liniment, the use of 
the cotton- jacket for the protection of the chest, and, if 
the child is very feverish, sponging it frequently with 
tepid water, and the use of a drop of sweet spirits of 
niter in a teaspoonful of cold water once in two hours or 
oftener, will constitute the nurse's management of the 
case until the doctor has seen the baby and laid down 
his plan of treatment. The cotton- jacket is made by tak- 



THE AILMENTS OF EARLY INFANCY. 265 

ing a high-necked, long-sleeved merino vest a size or two 
larger than would be needed by the baby for ordinary 
wear, opening it down the front, and fastening tapes an 
inch or two from each edge in front, by which the jacket 
may be closed. The inner surface of this vest, back and 
front, should be quilted with sheep's wool or cotton 
batting, the outer surface with oiled silk or oiled muslin. 
This makes a very warm covering for the chest. Some 
physicians employ compresses wrung out in cold water 
underneath the lined vest, renewing them frequently ; 
others prefer using warm flaxseed poultices. 

Infectious Diseases, such as scarlet fever, measles, 
etc., are very rare under the age of one year, especially 
under six months, therefore do not need to be considered 
here. Occasionally when the mother has the affection 
or has been where these diseases are immediately before 
or at the time of the baby's birth, the child will have the 
disease or develop it. The treatment must be managed 
by a physician. 

Cyanosis, or "blue disease," comes from the imperfect 
closure of an opening which exists in the heart before 
birth. The baby is called a "blue baby," and is very 
delicate in consequence of this imperfection in its cir- 
culation. Such babies generally die, if not during in- 
fancy, some time during early childhood. With great 
care they sometimes live, and the opening in the heart 
gradually closes up. The special care required is to 
keep the child warm and to handle it very carefully, so 
that it may be subjected to no jar or nervous fright. 



266 OBSTETRIC NURSING. 

The child should be kept lying on its right side, or on its 
back, in order that there may be as little interference as 
possible with the action of the heart, and that the tend- 
ency of the blood to flow through this opening in the 
upper chambers of the heart — from right to left — may 
be overcome. 

Rickets is a disease of the bones — the result of poor 
nutrition. There is not sufficient deposit of earthy 
matter in the bones, hence they remain too soft and are 
subject to all kinds of distortions in consequence of this. 
The child may be bow-legged and is stunted in its growth 
curvatures of the spine may exist, or an unnaturally 
large head, known as hydrocephalus, or " water on the 
brain." 

Scrofula is a term applied to a form of tuberculosis 
common among children. It shows itself in the tend- 
ency to enlargement of the glands, especially of the 
neck — the occurrence of abscesses and sore and weak 
eyes. Such cases should always be under the care of a 
physician. 

Marasmus is a term used to indicate a condition of 
presistent wasting in a child from whatever cause. The 
child becomes excessively thin, the skin yellowish, the 
face wrinkled. Tuberculosis, syphilis, persistent diai- 
rhea, and vomiting are apt to produce it. 

The baby having this disease is very weak, cannot 
hold up its head well, perspires very freely, especially 
about the head. The complexion is very white. The 
baby has constant trouble with its bowels, having green 



THE AILMENTS OF EARLY INFANCY. 267 

stools nearly all the time. The opening in the front of 
the head is depressed and the child seems to waste. 

As the baby grows older, unless well cared for, the 
evidences of disease increase, the joints are enlarged, 
the baby cannot support itself on its limbs, its teeth are 
slow in coming, etc. 

The mother can do much for the health of her child, 
while still cairying it, by a careful regard for her own 
general health. After the baby's birth it should be kept 
well nourished, to overcome any tendency to disease. 
Salt baths, oil baths, and the use of tonics ordered by the 
physician, as cod-liver oil, together with careful atten- 
tion to the quality and quantity of nourishment, will do 
much to prevent the progress of any wasting disease. 

Water on the Brain, or Hydrocephalus. — An enlarge- 
ment of the head is sometimes found even with very 
young infants, due to an accumulation of fluid within 
the skull, which results from a form of chronic inflam- 
mation. In mild cases the mind is not affected, and the 
child seems to outgrow the condition. 

Paralysis of one side of the face or of an arm some- 
times results from pressure during the birth. The baby 
usually recovers from this in a few weeks. Another 
form of paralysis sometimes occurs with infants which is 
due to disease of the spinal cord. These cases require 
intelligent medical super /ision. 

Vaccination. — The question often arises as to how 
early a baby should be vaccinated, particularly if small- 
pox be prevalent. As a matter of experience, it is 



268 OBSTETRIC NURSING. 

found that the vaccination does not "take" well before 
the third month, though if a younger baby is to be ex- 
posed to the poison, it would be well to have it vacci- 
ated. Vaccination should be avoided, if possible, when 
the baby's health is run down from any cause, also at 
the time of teething. A peculiar and distressing form of 
rash sometimes occurs, or there is a great deal of inflam- 
mation following the vaccination, leading the parents to 
imagine that the baby has been poisoned by the virus 
used. 

Care should be taken to see that the child does not 
scratch the sore, and that it is kept free from the rubbing 
of the clothing. No grease should be applied unless 
directed by the physician. When there is much redness 
and intense itching the physician may direct some pow- 
der or ointment to be applied to allay this. 

A soft, clean, linen handkerchief can be bound over 
the sore, and a loose-sleeved garment used to prevent 
the irritation of rubbing. Applications which are not 
aseptic, when used about such a sore may induce blood 
poisoning. 

An insight into the frailty of human life in its earliest 
days proves how much the world owes to the faithful- 
ness of mothers and nurses, and should be a stimulus to 
scientific research in the discovery of improved methods 
for the management of infancy. 



INDEX 



Abdominal bandages, 93 

Abortion, 64 

Accidents of labor, 1 21-136 
of pregnancy, 60 

After-birth,- delivery of, 131 

disposal of, 118, 132 
low > attachment of, 62 
position for delivery of, 13 
operative removal of, 132 

After-care of parturient, 133 

After-pains, 168 

Ailments of infancy, 224 

Airing of infant, 212 

Amenorrhea, 17 

Anesthesia, 137 

Aseptic dressings, 90 

Antiseptics, 106 

during labor, 107 

Artificial breathing, 124-129 

Attentions after labor, '118 

Auvard's couveuse, 226, 227 



B. 



Baby's basket, 97 

Baby's clothes, 93 

Bag of waters, 100 

Bandages, abdominal, 89 

for breasts, 90, 162, 164 
for varicose veins, 46 

Barley water, 240 

Bathing during lying-in, 152 
pregnancy, 5 1 

Bed, confinement, 91 
preparation, 109 

Bed-sores, 174 

Bier's suction hyperemia, 161, 167 

Binder for bady, 93 

for mother, 89 

Birth-marks, 248 

Bladder, 40, 153 

baby's, 250 

Bleeders, 262 

Bleeding from cord, 260 

Blisters, 249 

Boils, 251 

Bossi's dilator, 139 

Boston bandage, 163 



Bowel movements, 237 
Breast-pumps, 161 
Breasts, anatomy of, 15 

caked, 160 

care of , during lying-in, 156. 
pregnancy, 49 

gathered, 165 

of infants, 258 
Breech delivery, 81-83, 133, 140 
Bruises, 263 
Buhl's disease, 262 
Byrd-Drew Method of resuscitation, 125 



Caked breasts, 160 

Caput succedanum, 80 

Catheter, 153 

Cereals, 242 

Cesarean section, 142 

Chafing, 251 

Chart, order, 179 

Chorea, 54 

Cleansing of infant, 185 

Cleft palate, 259 

Clothing during pregnancy, 50 
for puerpera, 88 
of infant, 93, 185 
of nurse, 104 

Coccyx, 2 

Cold in head, 257 

Colic, 236 

Colostrum, 191 

Complications of pregnancy, 54 

Conception, 17 

Confinement, determining date, 36 

Constipation of infants, 245 

of mother, 38, 155 

Convulsions of infant, 263 

during labor, 135 

pregnancy, 67 

Cord, care of, 182 
tying, 130 

Couveuse, 225 

Cow's milk, 196 

modified, 198 

Cramps during labor, 115 

Craniotomy, 144 

Cranioclast, 143 

Cream, 198 

Crib, 187 



269 



270 



INDEX. 



Cries of infant, 
Cross-bed, 137 
Cyanosis, 265 



219 



G. 



D. 



Deformities of infants, 259 
Delivery, position for, 117 
Deportment of nurse; 136 
Development of infant, 213 
Diarrhea of infant, 238 
of mother, 39 
Diet after labor, 147 

during pregnancy, 52 

of infants, 189 
Dilatation by bags, 138 
Disinfection, 106 
Dress for mother, 88 
for nurse, 104 
Drink for baby, 244 
Duties of nurse during labor, 104 
Dysentery, 239 
Dysmenorrhea, 17 



Earache, 258 

Eclampsia, 67 

treatment of, 68, 69, 70 
hot pack for, 69 
symptoms of, 67 

Eczema, 249 

Emergencies of labor, 121 

of pregnancy, 60 

Emotions, maternal, 53 

Epilepsy, 54 

Erythema, 249 

Etherization, 137 

Examination during pregnancy, 56 

Exercise during pregnancy, 53 

Expression of infants, 220 

Eyes of new-born, 186, 253 



Falling of cord, 260 

Fallopian tubes, 14 

Farinaceous foods, 244 

Feeding in indigestion, 239 
of infants, 189 

Fever blisters, 252 

Fevers, 264 

Flour ball, 242 

Foetus, head, 71 

positions, 75 
presentations, 78 

Fontanelles, 72 

Food after labor, 147 

during pregnancy, 52 
of infancy, 200 

Forceps delivery, 140 

Formulae for infant feeling, 204 

Fresh air for infants, 213 



Galactagogues, 193 
Galactorrhea, 168 
Gavage, 235 
Gelatin, 240 
Genitalia, n 
Gertrude suit, 96 

H. 

Hair, baby's, 186, 215 
Hand feeding, 196 
Hare-lip, 259 
Head, fcetal, 71 

shape, 214 
Hearing of infants,- 215 
Heart trouble, 265 
Hematoma of scalp, 256, 259 
Hemorrhage during labor, 134 

pregnancy, 61 
packing the uterus for, 139 
Hemorrhoids, 45 
Hernia in infants, 246 
Human milk, 192 
Hydrocephalus, 267 

I. 

Incontinence of urine, 41 
Infants' foods, 189, 241 
Infectious diseases, 265 
Inflammation of bowels, 238 
Injections for infants, 245 

for mother, 126, 114 
Innominate bones, 2 
Insanity, 54, 175 
Internal examination, 
Involution, 149 
Itch, 25 



59 



Jaundice, 261 



Kidneys, 41 



J. 



K. 



L. 



Labor, mechanism, 71 

preparations for, 88 

signs of, 98 

stages of, 100 
Laborde's method of resuscitation, 12 
Lactation, 191 
Lactometer, 194 
Leucorrhea, 44 
Liebig foods, 244 
Lime water, 239 
Lion incubator, 228 
Lochia, 150 
Lying-in, 145 



INDEX, 



271 



M. 

Manual extraction of breech, 141 
Marasmus, 266 
Meconium, 184 
Mellin's food, 244 
Menorrhagia, 17 
Menstruation, 16 

Methods for calculating date of confine- 
ment, 32 
for resuscitation, 124 
Metrorrhagia, 17 
Miliaria, 249 
Milk, analysis, 192 

condensed, 241 

crust, 250 

foods, 241, 244 

leg, 173 

modified, 198 
Miscarriages, 70, 72 
Molding of infant's head, 215 
Morning sickness, 30 

N. 

Nervous diseases of pregnancy, 54 
Neuralgia, 47 
New-born, care of, 180 
Nipple protector, 158 

shield, 157 
Nipples, care of, 156 
rubber, 211 
Nursing bottle, 209 

O. 

Oatmeal water, 240 
Obstetric operations, 137 

preparation of patient for, 137 
preparation of instruments, 

137 
preparation for operator, 137 
Ophthalmia neonatorum, 253 
causes of, 253 
prevention of, 254 
treatment of, 254 
Order-chart, 179 
Outfit of baby, 93 

of mother, 88 
Ovaries, 15 
Ovum, development, 19 



Pains, false, 99 

of labor, 99 

true, 99 
Paralysis, 267 
Pasteurization, 200 
Pelvis, anatomy of, 1 

contents of, 1, 2, 3 

deformities, 6 

measurements of, 4, 57 
Peptonized food, 203 



Perforator, 143 
Perineorrhaphy, 138 
Phimosis, 251 
Piles, 45 
Placenta, 61, 65 
Positions of fcetal head, 75 
Powder, use of, 182 
Pregnancy, complications, 61 
management of, 38 
signs of, 27 
Premature rupture of membranes, 66 
Prematurity, 224 

Preparation of patient for labor, 1 06 
of room, 109 

of patient for examination, 
56 
Presentations of fcetus, 78 
Prickly heat, 249 
Prochownick's method of resuscitation, 

128 
Prolapse of cord, 136 
Pubiotomy, 141 
Puerperal fever, 172 
mania, 175 
ulcers, 173 
Pulse in hemorrhage, 134 
in infants, 218 
in lying-in, 172 
in pregnancy, 3 1 

Q. 

Quality food for infants, 197 
Quantity food for infants, 202 

R. 

Red gum, 248 

Respiration of infant, 217 

Resuscitation of infant, 124 

Rickets, 266 

Ring-worm, 252 

Rubber cloth, 91, 92 

Rules for feeding infants, 202 
for lying-in wards, 67-71 
for management couveuse, 227 
for premature infants, 232 

Running at ears, 257 

Rupture in infants, 246 

of membranes, 66 
of uterus, 136 

S. 

Sacrum, 1 
Salivary glands, 47 
Scalp tumors, 258 
Scrofula, 266 
Sea voyages, 52 
Senses, of infants, 215 
Sitting up (first) ,177 
Skin of infant, 213 
Sleep after labor, 145 
of infants, 217 



272 



INDEX. 



Snuffles, 257 

Soap suppository, 245 

Soiled clothing after labor, 145 

Sore eyes, 253 

mouth, 219 
Spice plaster, 237 
Sponge bath, 182, 187 
Sterilized milk, 206 
Sterilizer, 208 
Stomach of infant, 203 

rash, 249 
Stools of infant, 220 
Striae, 28 

Suppression of urine, 250 
Sutures, foetal, 71 
Swaddling, 230 
Syphilis, 54 
Syringe, 245 



U. 



Umbilical vegetations, 261 
Urinalysis, 42 

Urinary organs during pregnancy, 
Urination of infants, 220 
Uterus, 13 



V. 



Vaccination, 267 

Vagina, 13 

Varicose veins, 46 

Vernix caseosa, 180, 181 

Version, 140 

Visitors, 146 

Vomiting during labor, 115 

pregnancy, 48 
of infants, 247 



40 



Tact, 116 

Tarnier's couveuse, 225 

Teeth during pregnancy, 48 

of infants, 221 
Temperature of infant, 218 

of mother, 172 
Thrush, 247 

Toilet, first, of infant, 180 
Tongue-tie, 259 
Trachelorrhaphy, 138 
Training of infant, 189 
Transverse presentation, 85 
Tub, 188 
Twins, 131 
Tying cord, 130 



W. 

Walking of child, 223 
Washing for infants, 146 

for mother, 146 
"Water on the brain," 26 
Weaning, 243 
Weighing of infants, 186 
Weight of infant, 197, 216 
Wet-nurse, 191 
"Whites" in infants, 250 
Worms, 247 



Y. 



Y-bandage, 164 



m\ 



One copy del. to Cat. Div. 



It 191! 



